Motor Control Motor Learning Neural Plasticity

1. Title: ASSISTIVE TECHNOLOGY FOR
PHYSIOTHERAPY
Prepared by: Suad Ghaben Date: 00032020

2. Contents ..
• Overview of the foundation theories for sensory-motor rehabilitation.
• Overview of the Human Activity Assistive Technology Model “HAAT”, and the
Rehabilitation model.
• Physical Therapy Management in Assistive technologies: ,,,,,
• Overview of Assistive technologies designed for mobility: principles of design,
criteria of prescription, and The Best Practice Guideline from PT perspective.
• Walking aids: cane, crutches and walker
• Wheelchair: types, design, measurements, seating principles Fitting, and custom training
• Rehabilitation Robotics
• Overview of different types of Assistive technologies designed for positioning (Seating
technologies, and orthotics)
• Overview of Assistive technologies designed for environmental interaction.
• Overview of Assistive technologies designed for augmentation and alternative
communication.
• Overview of Assistive technologies designed for education.
• The socioeconomic aspects of AT .
• Standardization within AT field, and service delivery of AT,
• How to Establish new track related to “rehab tech” in physiotherapy practice
• Professionalism and ethical standards in Assistive Technologies

4. Overview of the Foundation
Theories for Sensory-Motor
Rehabilitation..
 MOTOR CONTROL (..)
 MOTOR LEARNING (..).
 NEURAL PLACITICITY (..)

5. Motor Control ..
• Motor Control (MC): is an explanation of how the central nervous system
(CNS), environment, and body systems interact and organize individual
joints and muscles to produce coordinated functional movement.
• “Motor control is the study of posture and movements that are
controlled by central commands and spinal reflexes, and also to the
functions of mind and body that govern posture and movement.”

6. MOTOR CONTROL THEORY..
The ability to regulate or direct the
mechanisms essential to Movement Learn
new way to control the movement
..

7. Movement emerges from three factors ..
• Individual – Action,
Perception, Cognition
• Task – Stability, Mobility,
Manipulation
• Environment – Regulatory,
Nonregulatory
Motor
control
Environment
Individual
Task

8. Cont ,,,
• The discipline of Motor Control is the study of human
movement and the systems that control it under normal and
pathological conditions.
• Depends upon -
• Environmental result of the movement (Outcome)
• Movement pattern
• Neuromotor processes underlying movement

9. Theories of Motor control ..
Reflex theory
Hierarchical theory
Complex systems theory
Motor Programming Theories
Systems Theory
Ecological Theory

10. Reflex theory (Charles Sherrington)..
• Complex behavior (movement)
is controlled by a series of
chained reflexes.
• Basic structure of a reflex:
• A: Receptor
• B: Conductor
• C: Effector
• If the chained or compounded
reflexes are the basis of
functional movement, clinical
strategies designed to test the
reflexes should allow the
therapist to predict functions.
• Patients movement behaviors
would be interpreted in terms
of presence or absence of
reflexes.
Clinical implications ..
Definition ..

11. Self..
• Unable to explain spontaneous
and voluntary movements
• – Movement can occur
without a sensory stimulus
eg- Fast sequential
movements, e.g. typing
• – A single stimulus can trigger
various responses (reflexes
can be modulated)
Limitations ..

12. Hierarchical theory (Jackson 1930s) ..
• Movement is controlled by a system
consisting of 3 levels with a rigid top
down organization
• Higher centers:
• always control lower centers
• inhibit reflexes controlled by lower
centers.
• Reflexes controlled by lower centers
are present only when higher
centers are damaged
• Each level of the motor system can
act on other levels
• Reflexes are not considered the soul
determinant of motor control
• “When the influence of higher
centers is temporarily or
permanently interfered with,
normal reflexes become
exaggerated and so called
pathological reflexes appear”
Brunnstrom,
• “The release of motor responses
integrated at lower levels from
restraining, influences of higher
center, especially that of the
cortex, leads to abnormal
postural reflex activity”…Bobath,
1965
Definition ..
Clinical implications ..

14. Hierarchical Theory ,,,
• This theory suggest that motor
control emerges from reflexes
that are nested within
hierarchically organized levels of
the CNS.
• – A child’s capacity to sit, stand,
and walk is related to the
progressive emergence and
disappearance of reflexes
• – Brain stem reflexes (associated
with head control) emerge
before midbrain reflexes
(associated with trunk control)

15. Complex (dynamic) systems theory ..
Definition
• Movement emerges as a result
of interacting elements.
• No needs for specific neural
commands or motor programs.
• Variability of movement is
normal.
• Optimal amount of variability
allows for flexible, adaptive
strategies to meet the
environmental demand
Clinical Implications
• This theory helps in
understanding the physical and
dynamic properties of human
body , we can make use of these
properties in helping the
patients to regain motor control
Definition .. Clinical implications ..

16. Motor Programming Theories ..
Definition
• Many studies found that movement
is possible even in the absence of
stimuli or sensory input
• – Sensory inputs are not required to
produce a movement but they are
important in adapting and
modulating the movement.
• Motor programs are
• – Hardwired and stereotyped neural
connections such as central pattern
generators (CPGs)
• – Abstract rules for generating
movements at the higher level
• Motor program can be activated by
sensory stimuli or by central
processes
Clinical Implications
• Movement problems are caused
by abnormal CPGs or higher
level motor programs
• It is important to help patients
relearn the correct rules for
action
• Focus on retraining movements
that are critical to a functional
task, not just specific muscles in
isolation
Definition .. Clinical implications ..

17. Systems Theory ..
Definition
• How does the CNS select a solution
from an infinite number of
possibilities for a task?
• Solution
• – Higher levels activate lower levels
while lower levels activate
synergies, i.e. groups of muscles
that are constrained to act together
as a unit.
• Viewed body as a mechanical
system, involving the interaction
between mass, external force (e.g.
gravity), internal force
• Body is a mechanical system.
Consider musculoskeletal
factors underlying a patient’s
movement problem
• Changes in movements may
not necessarily result from
neural changes, e.g. faster vs.
slow gait, speed during sit to
stand
• Encourage the patient to
explore variable movements
Definition .. Clinical implications ..

18. Systems Theory: Latash’s, Principle of
Abundance ..
• Synergy is a task-specific covariation of elemental variables with the
purpose to stabilize a performance variable, i.e. minimize errors of a
performance variable
• – Reaching: joint rotation angle stabilize hand position
• – Grasping: individual finger force stabilize total grasp force
• – Standing stability: postural muscle activation stabilize COP

19. Ecological Theory ..
Definition
• Action is specific to the task
goal and the environment
• Perceptual information of the
environmental factors relevant
to the task goal is necessary to
guide the action
• Limitations:
• – ↓ emphasis on nervous system
Clinical Implications
• Individual is an active explorer
of the environment for
learning
• Individual discovers multiple
ways to solve movement
problems in environment
• Fundamental to the play-
based therapy for pediatric
patients
Definition .. Clinical implications ..

20. Motor learning theory ,,,
• Motor learning is the understanding of acquisition and/or
modification of movement.
• As applied to patients, motor learning involves the reacquisition of
previously learned movement skills that are lost due to pathology or
sensory, motor, or cognitive impairments.
• This process is often referred to as recovery of function.

21. Learning vs. Motor Learning ..
• Learning is a process of acquiring knowledge about the world.
• Motor learning: a set of processes associated with practice
leading to a relatively permanent change in the capacity for skilled
actions
• Learning is a process of acquiring the capacity for skilled action
• Learning results from experience or practice
• Learning cannot be measured or observed directly; it is inferred
from behavior
• Learning produces relatively permanent changes in behavior;
short term change is not learning)

22. Motor Performance = Motor
Learning..
• Motor Performance is the temporary change in motor behavior
seen during a practice session
• e. g. A patient learns how to shift more body weight over the weaker
leg at the end of the therapy session.
• However, the patient still bears more weight on the unaffected leg at the
next visit to PT. Learning has not occurred.
• Performance may be influenced by many other variables, e.g.
fatigue, level of learning/skills, anxiety, motivation, cues or manual
guidance given to the learner
• Motor Learning is a relatively permanent change in motor
behaviors that are measured after a retention period and
only result from practice.

23. Forms of motor learning ..

24. Nondeclarative (Implicit) Learning:
Non-Associative Learning ….
• A single stimulus is given repeatedly and the nervous system learns
about the characteristics of the stimulus
• Habituation
• ↓ response to the stimulus, e.g. exercises to treat dizziness in patients
• Sensitization
• ↑ response to the stimulus, e.g. training to enhance awareness of loss of balance
• Classical Conditioning
• learn to predict relationships between two stimuli
• e.g. before learning: verbal cues + manual guidance stand up;
after learning: verbal cue stand up
• patients are more likely to learn if the associations are relevant and
meaningful

25. Nondeclarative (Implicit) Learning:
Associative Learning..
• Operant Conditioning
• learn to associate a certain response, from among many that
we have, with a consequence; trial and error learning
• e.g. relearn stability limits after ankle sprain; verbal praise
from PT behaviors that are beneficial and rewarded tend to
be repeated.

26. Procedural Learning ..
• Does NOT require attention, awareness, or other higher cognitive
processes
• One automatically learns the rules for moving, i.e. movement schema
• Learning requires repeating a movement continuously under a
variety of situations
• Patients with damage to cortex (e.g. TBI, dementia, aphasia) can still
increase performance

27. Declarative (Explicit) Learning ..
• Require attention, awareness, and reflection
• Results in knowledge or facts (e.g. objects, places, events) that can
be consciously recalled and expressed in declarative sentences,
• e.g. “1st I move to the edge of chair. 2nd I lean forward and stand
up”; instruction from PT; mental rehearsal; motor imagery.
•Practice can transform declarative into procedural or
nondeclarative knowledge
• e.g. a patient first learns to stand up may verbally repeat the
instruction; after repeated practice, the patient may be able to stand
up without instruction
• Processes of declarative learning:
• encoding consolidation storage retrieval

28. Theories of Motor learning ..
Adams Closed-Loop Theory
Schmidt Schema Theory
Ecological Theory
Fitts & Posner Three Stage
Model
Systems Three-Stage Model
Gentile’s Two Stage Model

29. Adams Closed-Loop Theory ..
•Clinical Implications
•Accuracy of a movement is proportional to
the strength of the perceptual trace
•Patient must practice the movement
repeatedly to ↑ the perceptual trace
•Limitations
•Cannot explain open loop movement

30. Schmidt Schema Theory ..
• Emphasizes open-loop control processes and generalized motor
program
• “Schema” is a generalized set of rules for producing movements
that can be applied to a variety of contexts
• Equivalent to motor programming theory of motor control
• Information stored in short-term memory after a
movement is produced
1.Initial movement conditions, e.g. body position, object wt, step
height
2.Parameters of a generalized motor program
3.Outcome of the movement, in terms of knowledge of results
4.Intrinsic sensory feedback of the movement

31. Schmidt Schema Theory ..
• Information stored in short-term memory is converted into two
schemas
1.Recall schema selects a specific response and contains rules for
producing a movement
2.Recognition schema evaluates the response correctness and informs
the learner about the errors of a movement.
• Clinical Implication: Variability of practice↑ learning and
generalized motor program rules
• Limitations
• Vague; no consistent research finding in support of variable
practice
• Cannot account for one-trial learning (In the absence of a
schema)

32. Ecological Theory ..
• Learning involves the
exploration the perceptual and
motor workspace
1.Identify critical perceptual
variables, i.e. regulatory cues
2.Explore the optimal or most
efficient movements for the task
3.Incorporate the relevant
perceptual cues and optimal
movement strategies for a specific
task

33. Ecological Theory ..
•Clinical Implications
•Patients learn to identify relevant perceptual cues that
are important for developing appropriate motor
responses,
•e.g. identify relevant perceptual cues for reaching and
lifting a heavy glass: weight, size, or surface of the
glass vs. its color?

34. Fitts & Posner Three Stage Model ..
• Phases of motor learning
• Phase 1: Early or Cognitive Phase
• Phase 2: Intermediate or
Associative phase
• Phase 3 : Final or Autonomous
Phase
Cognitive Phase
Associative phase
Autonomous

35. Cognitive Phase ..
• Learner activities
• Learn what to do
• Learn about the task and goals
• Require high degree of attention
• Select among alternative strategies
• Performance may be more variable
• Fast improvement in performance
• Develop a motor program

36. Associative phase ..
•Learner activities
• Refine the skills
• Refine a particular movement
strategy
• Performance is less variable and
more consistent
• Cognitive monitoring decreases
• Improve the organization of the
motor program

37. Autonomous Phase ..
•Learner activities
•Become proficient, save energy
•Attention demands are greatly reduced
•Movements and sensory analysis begin to become
automatic
•Able to perform multiple tasks, scan the
environment
•Ability to detect own errors improves

38. Implications for PT Rehabilitation..
• Motor learning probably occurs in stages
• Activities of the patient are different in the different stages
• Activities of the therapist should be different in the different
stages

39. Systems Three-Stage Model ..
• Learners initially restrict degrees of freedom
(DOF) and gradually release the DOF as the
task is learned and the skills improve
• Novice Stage
• Simplify movement by constraining joints and
↓DOF, e.g. muscles co-contraction - Less energy
efficient
• Advanced Stage
• Gradual release of additional DOF
• More adaptive to different contexts
• Expert Stage
• All DOF released
• Efficient and coordinated movements
• Exploit the mechanical and inertial properties of
Novice stage
Advanced stage
Expert Stage

40. Gentile’s Two Stage Model ..
• Early stage
• Understand the task goals, develop
• movement strategies, recognize
• regulatory features of the
environment
• Late stage
• Refine the movement, consistent
and efficient performance
• Closed skills become
fixation/consistent
• Opened skills become
diversification/adaptive
Early stage
Late stage

41. Self..
• Self

42. Application of motor learning theories ..
How to Measure Learning?
To separate the relatively permanent effects of learning
from the transient effect of practice, learning can be
measured using retention or transfer designs.
1.Test the subject after a retention interval, typically >= 24 hr
2.Choose the same task (retention test) or a variation of the
task (transfer test)(e.g. different speed or lighting conditions
for walking)

43. Consideration..
• Practice Level: How Much?
• PRACTICE, PRACTICE, PRACTICE
• Animal Studies: 9,600 retrievals over 4 week period.
• Feedback (FB)
• FB is all the sensory information that is available as a results of a
movement
• Types by mode of delivery
• Intrinsic (e.g. proprioception)
• Extrinsic (e.g. instruction from PT)
• Types of FB by information provided
• Knowledge of results (KR)
• Knowledge of performance (KP)

44. Types of FB ..
• Knowledge of Performance (KP)
• Information about the movement patterns
• Usually intrinsic but can also be extrinsic
• Proprioception, Biofeedback, video recording, verbal
instruction (e.g. “Your elbow was /is in flexed.”)
•Knowledge of Results (KR)
• Information about the result or outcome of the movement
in terms of the goal
• Verbal instruction - proprioception (e.g. feeling loss of
balance during a fall)

45. Characteristics of Good Feedback..
• Timing: Allow some time to reflect between trials
• Summary FB
• Summary FB after a few trials works better than after every trial
• Give more frequent summary feedback (e.g. after every 5 trials) for complex tasks than
for simple tasks.
• Accuracy: Positively reinforce correct performance
• Augmented (extrinsic) Feedback
• Video/visual of movement patterns alone does not help; need to provide error correcting cues as
well
• AVOID VERBAL BOMBARDMENT
• Can be given concurrently or afterwards
• Frequency and Fading Schedule
• More impaired patients may require more frequent FB.
• Avoid giving FB every trial.
• Decrease the amount of FB given across learning stages so the patients won’t become dependent
on FB.

46. Motor learning ..
• Motor re-learning is comparable to motor learning
• Patients have capacity to learn ..
• Motor learning requires:
• Practice –encompassing skills acquisition, motor adaptation
and decision making
• Successful practice
• High numbers of repetitions
• High intensity and/or dosage
• Sensory priming
• Variable practice
• Provision of feedback
• Complex integration of cognition-perception and action processes

47. Phases of motor learning ..
 Phase 1: Early or Cognitive Phase
 Phase 2: Intermediate or Associative phase
 Phase 3 : Final or Autonomous Phase
 Optimize Cognitive Aspects of Learning:
 Instructions
 Feedback
 Nature of Practice
 Augmented feedback: Feedback given from an external source
which is additional to the perception of the mover
 Information re:
 Knowledge of Results (KR) or
 Knowledge of Performance (KP)

48. Neural plasticity ..

49. Neural Plasticity ,,,
• Is the ability of neurons to change their function, chemical
profile or structure.
•Neuroplasticity includes :
• Habituation
• Learning & memory
• Cellular recovery after injury

50. Neural Plasticity ..
• In some cases, patients with brain
damage have healed naturally because
healthy nerves took on tasks of
damaged or destroyed nerves, allowing
for some level of functionality.
• Variety of mechanisms by which
neuronal plasticity can occur;
• Axonal sprouting
• Synaptic pruning

51. Axonal sprouting ..
• Healthy axons sprout new nerve
endings that connect to other
pathways in the nervous
system.
• This can be used to strengthen
existing connections or to
repair damaged parts of the
nervous system by repairing
damaged neural pathways and
restoring them to full

52. Synaptic pruning ..
• Synaptic pruning refers to the process by which extra neurons and
synaptic connections are eliminated in order to increase the efficiency of
neuronal transmissions.

53. LEARNING & MEMORY ..
• During motor learning large & diffuse regions of the brain show
synaptic activity.
• With repetition of a task, there is a reduction in no. of active regions in
the brain
• - long-term memory (LTM) requires the synthesis of new
proteins & the growth of new synaptic connections, with
repetition of specific stimulus synthesis & activation of new
proteins promote the growth of new synaptic connections.
#Neuroplasticity is activity driven, follows use it or lose it rule ..
#New activity generates new connections
#frequently used synapsis are strengthened,
#rarely used connections are weakened or eliminated

54. Cellular Recovery from Injury ..
• Injuries that damage or severe
the axons of neurons cause
degenerative changes but may
not result in death of the cell.
• Axonal Injury – walerian
degeneration,
• sprouting – collateral sprouting,
Regenerative sprouting
• Synaptic changes - oedema

55. Self..
• Self

56. Rehabilitation & Neuroplasticity ..
 Components – cell genesis & repair
 Alteration of existing neuronal pathways
 Formation of new neural connections

57. Three Principles of Neuroplasticity ..
• 1. Motor skilled practice –practice of motor skills with enough repetition
enhances both the adaptive changes in the brain & improve skills.
• In peds & adult setting the MOVE Programme is structured method for
encouraging intensive motor skill practice.
• - MOVE – is a philosophy ….. A way of life & proven practice that
individuals with multiple disabilities can learn to
• - SIT –to eat participate in activities, education & even employment.
• STAND – such as washing a sink, food preparation & upright toileting.
• WALK – to move to participate in play or complete tasks (with or without
support)
• TRANSITION – from bed to chair, sitting to standing.

58. 2. Enriched environment – providing the recovering brain with
stimuli such as increased physical activity, more social interaction,
problem solving opportunities; enhances both functional recovery&
underlying neural processes including synaptic plasticity.
3. Aerobic exercises – physical activity in itself, particularly
aerobic activity enhances neural plasticity

59. Effects of Rehabilitation on Plasticity
..
1. Physical training & exercises –
- Constrained Induced Movement Theory (CIMT)
- Body weight –supported treadmill training
- Robotic devices
- Behavioural shaping (Psychology) – managing inappropriate behavior
– e.g – homework & reward
-Bilateral arm training
- Task oriented physical therapy
2. Aerobic exercises –
3. Cognitive training / brain training –
Improvement of a number of cognitive skills including
attention, working on memory, problem solving skills/
abilities, reading.

60. Theoretical model ..

61. Environmental enrichment ..
• Studies show that an enriched environment promotes
sensorimotor recovery after stroke.
• should provide sensory, motor, cognitive & motor
stimulation.
• Multilodal stimulation includes tactile massage, therapeutic
gardens, music, rhythm, cognitive, challenges, motor
imagery & mental training etc.

62. Neurotransplantation &
Stereotaxic Surgical Approaches
,,,
1. Deep Brain Stimulation
2. Neuronal transplant/Implant
3. Stereotaxic Surgery

63. Self..
• Self

64. Thank You
Keep connected with i-CARE project:
Email: icare@alazhar.edu.ps
i-CARE website
i-CARE Facebook Page
Office Address: K3 Building, Katiba Compound, Six Floor,
Al Azhar University – Gaza, Palestine.