6

Section I

THEORETICAL FRAMEWORK

is assumed t o be a m a j o r d e t e r m i n a n t o f abn o r m a l f u n c t i o n . As a result, n u m e r o u s approaches have been developed t o assess and treat spasticity i n the course o f r e t r a i n i n g f u n c t i o n . H o w e v e r , because there are m a n y different theories a b o u t the nature and cause o f m o v e m e n t , there are p o t e n t i a l l y many o t h e r therapeutic approaches f o r r e t r a i n i n g m o t o r dyscontrol. NEW IDEAS: D Y N A M I C A N D EVOLVING Theories are d y n a m i c , and change t o reflect greater k n o w l e d g e r e l a t i n g t o the theory. H o w does this affect clinical practices related t o r e t r a i n i n g m o t o r dyscontrol? C h a n g i n g and expanding theories o f m o t o r c o n t r o l need n o t be a source o f f r u s t r a t i o n t o clinicians. Exp a n d i n g theories can broaden and enrich the possibilities f o r clinical practice. N e w ideas f o r the assessment and t r e a t m e n t o f m o t o r dysc o n t r o l w i l l evolve t o reflect n e w ideas a b o u t the nature and cause o f m o v e m e n t . W O R K I N G HYPOTHESES FOR ASSESSMENT A N D T R E A T M E N T A t h e o r y is n o t directly testable, since i t is abstract. Rather, theories generate h y p o t h eses, w h i c h are testable. I n f o r m a t i o n gained t h r o u g h hypothesis testing is used t o validate o r invalidate a t h e o r y . T h i s same approach is useful i n clinical practice. So-called hypothesisdriven clinical practice ( 4 ) transforms the therapist i n t o an active p r o b l e m solver. U s i n g this approach t o retrain m o t o r d y s c o n t r o l calls for the therapist t o generate m u l t i p l e h y p o t h eses (explanations) f o r w h y patients m o v e ( o r d o n ' t m o v e ) i n ways t o achieve f u n c t i o n a l i n dependence. D u r i n g the course o f therapy the therapist w i l l test various hypotheses, discardi n g some, and generating n e w explanations t h a t are m o r e consistent w i t h their results.

Figure 1.2. Mrs. Johnson is a 67-year-old woman referred for therapy because of a right cerebral vascular accident resulting in a left hemiparesis. Pictured is her habitual sitting posture.

f u n c t i o n , specifically the inability t o actively e x t e n d the e l b o w , t o be p r i m a r i l y the result o f s p a s t i c i t y , defined as a release of the stretch reflex, i n the e l b o w flexors. Has y o u r theoretical f r a m e w o r k helped y o u t o correctly i n t e r p r e t this patient's behavior? O n l y i f this patient's problems are i n fact solely the result o f spasticity. T h e t h e o r y has n o t helped y o u as a clinician i f i t has l i m i t e d y o u r ability t o explore o t h e r possible explanations f o r y o u r patient's behavior. W h a t are some o f the o t h e r factors t h a t p o t e n t i a l l y i m pair a r m f u n c t i o n i n y o u r stroke patient? Later i n this chapter w e w i l l discuss other theories o f m o t o r c o n t r o l that w i l l p r o v i d e alternative explanations f o r loss o f f u n c t i o n . GUIDE FOR CLINICAL ACTION Theories p r o v i d e therapists w i t h a possible guide f o r action. C l i n i c a l practices designed t o treat the p a t i e n t w i t h m o t o r dysc o n t r o l are based o n an u n d e r s t a n d i n g o f the nature a n d cause o f n o r m a l m o v e m e n t , as w e l l as an u n d e r s t a n d i n g o f the basis f o r a b n o r m a l m o v e m e n t . Therapeutic strategies a i m e d at r e t r a i n i n g m o t o r c o n t r o l reflect this basic u n derstanding. I n the above example, spasticity

upon which much Therapists are reco past theories and o f n e w solutions b t o r c o n t r o l and re I n this sectio m o t o r c o n t r o l and itations and possib i m p o r t a n t t o unde u n i f i e d by the desi and cause o f m o v e the approach. I t is five m e n t r y i n g t o f u n c t i o n o f an ele systematically stud e r y t h i n g there is and f u n c t i o n o f the nature and f u n c t i o tail. Each i n his ov tial i n f o r m a t i o n a ever, a true under and f u n c t i o n o f a by c o m b i n i n g info this spirit, w e app o n theories o f m tions, and possible

Ref

Sir Charles I ologist i n the lat w r o t e the b o o k 7 Nervous System i n the experimental flex t h e o r y o f mot> reflexes were the plex behavior. Re

Receptor

THEORIES OF MOTOR CONTROL

There is tremendous enthusiasm a m o n g therapists f o r critically e x a m i n i n g the models

Stimulus

Figure 1.3. The bas receptor, a conducto

Chapter One

THEORIES OF M O T O R C O N T R O L

u p o n w h i c h m u c h o f clinical practice is based. Therapists are r e c o g n i z i n g the l i m i t a t i o n s o f past theories a n d the e x p a n d i n g possibilities o f n e w solutions based o n n e w models o f m o t o r c o n t r o l a n d recovery o f f u n c t i o n . I n this section w e w i l l review theories o f m o t o r c o n t r o l a n d explore some o f their l i m itations a n d possible clinical implications. I t is i m p o r t a n t t o u n d e r s t a n d t h a t all models are unified b y the desire t o u n d e r s t a n d the nature and cause o f m o v e m e n t . T h e difference is i n the approach. I t is n o t u n l i k e the story o f the five m e n t r y i n g t o u n d e r s t a n d the nature a n d f u n c t i o n o f an elephant. O n e carefully and systematically studies the t r u n k , a n d learns eve m h i n g there is t o k n o w a b o u t the nature and f u n c t i o n o f the t r u n k . A n o t h e r studies the nature a n d f u n c t i o n o f the feet; another, the tail. Each i n his o w n way has p r o v i d e d essential i n f o r m a t i o n a b o u t the elephant. H o w ever, a t r u e u n d e r s t a n d i n g a b o u t the nature and f u n c t i o n o f an elephant is o n l y possible c o m b i n i n g i n f o r m a t i o n f r o m all sources. I n this spirit, w e approach the f o l l o w i n g section o n theories o f m o t o r c o n t r o l , t h e i r l i m i t a tions, and possible clinical applications.

Stimulus

Response ' (stimulus)

Response (stimulus)

Figure 1.4. Reflex chaining as a basis for action. A stimulus leads to a response, which becomes the stimulus for the next response, which becomes the stimulus for the next response.

insequence, t o achieve a c o m m o n purpose (5). S h e r r i n g t o n p e r f o r m e d elegant experiments w i t h cats, dogs, a n d monkeys t o show the existence o f the reflex, a n d t o carefully describe a n d define reflexes. T h e c o n c e p t i o n o f a reflex requires three different structures, as s h o w n i n Figure 1.3: a receptor, a c o n d u c t i n g nervous pathway, a n d an effector. T h e c o n d u c t o r consists o f at least t w o nerve cells, one connected t o the effector, the o t h e r c o n nected t o the receptor. T h e reflex arc t h e n consists o f the receptor, the c o n d u c t o r , a n d the effector ( 6 ) . S h e r r i n g t o n w e n t o n t o describe c o m plex behavior i n terms o f c o m p o u n d reflexes, and their successive combination or chaining together. S h e r r i n g t o n gave the f o l l o w i n g example o f a f r o g c a p t u r i n g a n d eating a fly. Picture M r . T o a d s i t t i n g i n the sun o n his l i l y p a d . A l o n g comes the fly; seeing the fly ( s t i m ulus) results i n the reflex activation o f the t o n g u e d a r t i n g o u t t o capture the fly (response). I f he is successful, the contact o f the fly o n the t o n g u e causes reflex closure o f the m o u t h , a n d closure o f the m o u t h results i n reflex s w a l l o w i n g . S h e r r i n g t o n c o n c l u d e d t h a t w i t h the w h o l e nervous system i n t a c t , the reaction o f the various parts o f t h a t system, the simple reflexes, are c o m b i n e d i n t o greater actions, w h i c h constitute the behavior o f the i n d i v i d ual as a w h o l e . Figure 1.4 represents this c o n cept o f reflex c h a i n i n g . Sherrington's v i e w o f a reflexive basis f o r m o v e m e n t persisted u n challenged f o r 50 years, and continues t o i n fluence t h i n k i n g a b o u t m o t o r c o n t r o l today. LIMITATIONS Because S h e r r i n g t o n l o o k e d p r i m a r i l y at reflexes, and asked questions a b o u t the central

t o reD the theory, crices related Ir C h a n g i n g c o n t r o l need iinicians. Exad e n r i c h the S e w ideas f o r m o t o r dysr ideas a b o u t m: DR IENT abte. since i t crate h y p o t h r^iz: r. gained n i t o validate :c i r r r o a c h is l e d bypothesisBDsforms the isotvcr. U s i n g (rsconrrol calls Arjpie h y p o t h ients move ( o r functional i n o t therapy the beses. discardr explanations heir results.

Reflex Theory
Sir Charles S h e r r i n g t o n , a n e u r o p h y s i ologist i n the late 1800s and early 1900s, w r o t e the b o o k The Integrative Action of the Nervous System i n 1906. H i s research f o r m e d the experimental f o u n d a t i o n f o r a classic reex t h e o r y o f m o t o r c o n t r o l . F o r S h e r r i n g t o n , reflexes were the b u i l d i n g blocks o f c o m plex behavior. Reflexes w o r k e d t o g e t h e r , o r

eceptor

Muscle/ effector

OTOR
5: ~ulus among the models Response

Figure 1.3. The basic structure of a reflex consists of a wreptor, a conductor, and an effector.

Section I

THEORETICAL

FRAMEWORK

nervous system ( C N S ) related d r e w a p i c t u r e o f the C N S and t h a t was skewed towards reflex are a n u m b e r o f l i m i t a t i o n s o f o f m o t o r control (1).

t o reflexes, he motor control control. There a reflex t h e o r y

CLINICAL IMPLICATIONS H o w m i g h t a reflex t h e o r y o f m o t o r c o n t r o l be used t o i n t e r p r e t a patient's behavi o r , and serve as a guide for the therapist's actions? I f chained o r c o m p o u n d e d reflexes are the basis for f u n c t i o n a l m o v e m e n t , clinical strategies designed t o test reflexes s h o u l d all o w therapists t o predict f u n c t i o n . I n addition, a patient's m o v e m e n t behaviors w o u l d be i n t e r p r e t e d i n terms o f the presence o r absence o f c o n t r o l l i n g reflexes. Finally, retraini n g m o t o r c o n t r o l f o r f u n c t i o n a l skills w o u l d focus o n enhancing o r r e d u c i n g the effect or various reflexes d u r i n g m o t o r tasks. A p p l y i n g a reflex theory t o i n t e r p r e t i n g m o t o r dyscont r o l was s h o w n i n o u r previous example o f M r s . Johnson. Clinical strategies f o r i m p r o v i n g m o t o r c o n t r o l using a reflex m o d e l w o u l d focus o n methods t o reduce flexor spasticity, w h i c h s h o u l d enhance n o r m a l m o v e m e n t capacity. Despite the Umitations i n Sherrington's conclusions, m a n y o f his assumptions about h o w the C N S controls m o v e m e n t have been reinforced and have influenced current clinical practices.

T h e reflex c a n n o t be considered the basic u n i t o f behavior i f b o t h spontaneous and v o l u n t a r y movements are recognized as acceptable classes o f behavior, since the reflex m u s t be activated by an outside agent. A n o t h e r l i m i t a t i o n o f the reflex t h e o r y o f m o t o r c o n t r o l is that i t does n o t adequately explain a n d predict m o v e m e n t t h a t occurs i n the absence o f a sensory stimulus. M o r e recently, i t has been s h o w n t h a t animals can move i n a relatively c o o r d i n a t e d fashion i n the absence o f sensory i n p u t ( 7 ) . Yer another l i m i t a t i o n is t h a t the t h e o r y does n o t explain fast movements, that is, sequences o f movements that occur t o o rapidly t o a l l o w f o r sensory feedback f r o m the preceding m o v e m e n t t o trigger the next. F o r example, an experienced and p r o f i c i e n t typist moves f r o m one key t o the next so rapidly that there isn't t i m e f o r sensory i n f o r m a t i o n f r o m one keystroke t o activate the next. A n a d d i t i o n a l l i m i t a t i o n is t h a t the reflex c h a i n i n g m o d e l fails t o explain the fact t h a t a single stimulus can result i n v a r y i n g responses d e p e n d i n g o n c o n t e x t and descending c o m mands. F o r example, there are times w h e n we need t o override reflexes t o achieve a goal. F o r example, n o r m a l l y t o u c h i n g s o m e t h i n g h o t results i n the reflexive w i t h d r a w a l o f the h a n d . H o w e v e r , i f o u r c h i l d is i n a fire, we may override the reflexive w i t h d r a w a l t o p u l l the c h i l d out. Finally, reflex c h a i n i n g does n o t explain the ability t o produce novel movements. N o v e l movements p u t together u n i q u e c o m binations o f s t i m u l i and responses according t o rules previously learned. A v i o l i n i s t , w h o has learned a piece o n the v i o l i n , and also k n o w s the technique o f p l a y i n g the cello, can play t h a t piece perfectly o n the cello w i t h o u t necessarily h a v i n g practiced the piece o n the cello. T h e v i o l i n i s t has learned the rules f o r p l a y i n g the piece and has applied t h e m t o a novel o r n e w situation.

Hierarchical Theory
M a n y researchers c o n t r i b u t e d t o the v i e w t h a t the nervous system is organized as a hierarchy. A m o n g t h e m , H u g h l i n g s Jackson, an E n g l i s h physician, argued t h a t the b r a i n has higher, m i d d l e , and l o w e r levels o f c o n t r o l , equated w i t h h i g h e r association areas, the m o t o r cortex and spinal levels o f m o tor function (8). Hierarchical c o n t r o l i n general has been defined as an organizational structure that is top down. T h a t is, each successively higher level exerts c o n t r o l over the level b e l o w i t , as s h o w n i n Figure 1.5. I n a strict vertical hierarchy, lines o f c o n t r o l d o n o t cross and there is never b o t t o m u p c o n t r o l . I n the 1920s, R u d o l f M a g n u s began t o explore the f u n c t i o n o f different reflexes w i t h i n different parts o f the nervous system.

tmtM.-.mmtmmn

mmmmmmmmmu

Chapter One

T H E O R I E S OF M O T O R C O N T R O L

Top

A
r i g i i L. 1-5.

The hierarchical control structure is char" z-zow n structure, where higher centers a e a h a a v * in charge of lower centers.

r~: that reflexes c o n t r o l l e d by lower i r c c b o f the neural hierarchy are o n l y present wmen cortical centers are damaged. These rel i t e r interpreted t o i m p l y that re-: : : r i r t o f a hierarchy o f m o t o r c o n t r o l , r w- ; - r r g r e r centers n o r m a l l y i n h i b i t these k p c r reflex centers ( 9 - 1 0 ) . Georg Schaltenbrand ( 1 1 ) used ~c : ~ ; : r t - developed by M a g n u s t o explain r : : . .-. r r t e n t o f m o b i l i t y i n c h i l d r e n and dC_r: H : described the development o f h u n s r mobility i n terms o f the appearance and m LTCci.-ir.ee o f a progression o f reflexes. H e w e n t o n f u r t h e r t o say that p a t h o l o g y o f the b r a n IRZY result i n the persistence o f p r i m i t i v e :": : H ; suggested that a complete u n . : : - - . : : r . f all the reflexes w o u l d allow the ; . : - : - i t : r. o f the neural age o f a c h i l d or pnbent. I n the late 1930s, Stephan Weisz ( 1 2 ) x_r:rEed o n reflex reactions t h a t he felt were r-jsis for e q u i l i b r i u m i n humans. H e de<-A the o n t o g e n y o f e q u i l i b r i u m reflexes -JC n o r m a l l y developing c h i l d and p r o j c s c i i a relationship between the m a t u r a t i o n 'rrexes and the child's capacity t o sit, a n d , and w a l k . T h e results o f these experiments and _r r.s were drawn together and are of. ed t o i n the clinical literature as a r i r c h i c a l theory o f m o t o r c o n t r o l . I k s reflex/hierarchical t h e o r y o f m o t o r c o n rr.es reflex and hierarchical theories mcD o n e . T h i s t h e o r y suggests t h a t m o t o r .. err erterges f r o m reflexes t h a t are nested

w i t h i n hierarchically organized levels o f the CNS. I n the 1940s, A r n o l d Gesell ( 1 3 , 14) and M y r t l e M c G r a w ( 1 5 ) , t w o w e l l - k n o w n developmental researchers, offered detailed descriptions o f the m a t u r a t i o n o f infants. These researchers applied the c u r r e n t scientific t h i n k i n g about reflex hierarchies o f m o t o r c o n t r o l t o explain the behaviors they saw i n infants. N o r m a l m o t o r development was att r i b u t e d t o increasing corticalization o f the C N S resulting i n the emergence o f h i g h e r levels o f c o n t r o l over l o w e r level reflexes. T h i s has been referred t o as a neuromaturational theory o f development. A n example o f this m o d e l is illustrated i n F i g u r e 1.6. This t h e o r y assumes t h a t C N S m a t u r a t i o n is the p r i m a r y agent f o r change i n development. I t m i n i mizes the i m p o r t a n c e o f o t h e r factors such as musculoskeletal changes d u r i n g development. Since H u g h l i n g s Jackson's o r i g i n a l w o r k , a n e w concept o f hierarchical control has evolved. M o d e r n neuroscientists have c o n f i r m e d the i m p o r t a n c e o f elements o f h i erarchical o r g a n i z a t i o n i n m o t o r c o n t r o l . T h e concept o f a strict hierarchy, where higher centers are always i n c o n t r o l , has been m o d i fied. C u r r e n t concepts describing hierarchical c o n t r o l w i t h i n the nervous system recognize the fact that each level o f the nervous system can act u p o n other levels (higher a n d l o w e r ) d e p e n d i n g o n the task. I n a d d i t i o n , the role o f reflexes i n m o v e m e n t has been m o d i f i e d . Reflexes are n o t considered the sole determ i n a n t o f m o t o r c o n t r o l , b u t o n l y one o f many processes i m p o r t a n t t o the generation and c o n t r o l o f m o v e m e n t . LIMITATIONS O n e o f the l i m i t a t i o n s o f a reflex/hierarchical t h e o r y o f m o t o r c o n t r o l is t h a t i t cann o t explain the dominance o f reflex behavior i n certain situations i n n o r m a l adults. F o r example, stepping o n a p i n results i n an i m m e diate w i t h d r a w a l o f the leg. T h i s is an example o f a reflex w i t h i n the lowest level o f the hierarchy d o m i n a t i n g m o t o r f u n c t i o n . I t is an ex-

10

Section I

THEORETICAL FRAMEWORK

Neuroanatomical structures

Postural reflex development

Motor development

Cortex

Equilibrium reactions

Bipedal function

Midbrain Righting reactions Quadrupedal function

Brainstem spinal cord

Primitive reflex

Apedal function

Figure 1.6. Neuromaturational theory of motor control attributes motor development to the maturation of neural processes, including the progressive appearance and disappearance of reflexes.

ample o f b o t t o m - u p c o n t r o l . T h u s , one m u s t be cautious a b o u t assumptions t h a t all l o w level behaviors are p r i m i t i v e , i m m a t u r e , a n d nonadaptive, w h i l e all h i g h e r level (cortical) behaviors are m a t u r e , adaptive, a n d a p p r o p r i ate. CLINICAL IMPLICATIONS A b n o r m a l i t i e s o f reflex o r g a n i z a t i o n have been used by m a n y clinicians t o explain disordered m o t o r c o n t r o l i n the n e u r o l o g i c a l patient. Berta B o b a t h , an E n g l i s h physical therapist, i n her discussions o f a b n o r m a l post u r a l reflex activity i n c h i l d r e n w i t h cerebral palsy, states t h a t " t h e release o f m o t o r responses i n t e g r a t e d at l o w e r levels f r o m restraining influences o f h i g h e r centers, especially t h a t o f the cortex, leads t o a b n o r m a l postural reflex a c t i v i t y " ( 1 6 ) . Based o n a reflex/hierarchical t h e o r y o f m o t o r c o n t r o l and development, a number o f reflex tests have been developed as p a r t o f the clinical assessment o f patients w i t h n e u r o l o g ical i m p a i r m e n t s ( 1 7 ) . These reflex assessment profiles are used t o estimate the level o f neural m a t u r a t i o n a n d p r e d i c t f u n c t i o n a l ability. I n a d d i t i o n , reflex profiles are used t o d o c u m e n t the presence o f persisting a n d d o m i n a t i n g p r i m i t i v e a n d p a t h o l o g i c a l reflexes believed

t o be m a j o r deterrents t o n o r m a l m o t o r control. A n u m b e r o f treatment approaches have been developed w h i c h focus o n enhancing o r r e d u c i n g the efficacy o f reflexes as an i m p o r tant step i n r e t r a i n i n g m o t o r c o n t r o l . T h e goal o f t r e a t m e n t is t o achieve greater f u n c tion t h r o u g h the m o d i f i c a t i o n o f reflex action. O n e o f the difficulties i n using a reflex approach t o r e t r a i n i n g m o t o r c o n t r o l is that successful m o d i f i c a t i o n o f reflex activity is n o t always m i r r o r e d i n i m p r o v e m e n t s i n f u n c t i o n a l skills. Part o f the d i f f i c u l t y may he i n the issue o f f o c u s i n g t r e a t m e n t o n reactions instead o f preparing patients f o r action.

move the m w e are left w i pattern. This m o r e flexible cause i t can s t i m u l i o r by A moto t r o l has cons F o r example, studied the gr t h a t t h e timi flight depend erator. Even cut, the n e r v erate the o u t p ever, the w i n g gested that m absence o f r e w h i l e n o t esse an i m p o r t a n t These conclus work examinin results o f thes the cat, spinal n a locomotor r inputs o r desce By changing t the spinal c o r d walk, t r o t , o r g that reflexes d o tral p a t t e r n gen erate such c o m t r o t , a n d gallop the i m p o r t a n t m sensory i n p u t s tor (22).

Motor Programming Theories

M o r e current theories o f m o t o r c o n t r o l have expanded o u r u n d e r s t a n d i n g o f the C N S . T h e y have m o v e d away f r o m views o f the C N S as a m o s t l y reactive system a n d have b e g u n t o explore the p h y s i o l o g y o f actions rather t h a n the p h y s i o l o g y o f reactions. Reflex theories have been useful i n exp l a i n i n g certain stereotyped patterns o f m o v e m e n t . H o w e v e r , an interesting way o f v i e w i n g reflexes is t o consider t h a t one can remove the stimulus, o r the afferent i n p u t , a n d still have a p a t t e r n e d m o t o r response ( 1 8 ) . I f w e re-

These ex program theory has been used i n researchers, so m i n i n g h o w the motor prograr central p a t t e r n specific neural c w a l k i n g i n the c resents neural c t y p e d a n d hardw B u t the t e n t o describe the 1 that represent ac

Chapter One

THEORIES OF M O T O R C O N T R O L

11

m o v e the m o t o r response f r o m its stimulus, we are left w i t h the concept o f a central m o t o r pattern. T h i s concept o f a m o t o r p a t t e r n is m o r e flexible t h a n the concept o f a reflex because i t can either be activated by sensory s t i m u l i o r b y central processes. A m o t o r program theory o f m o t o r cont r o l has considerable experimental support. For example, experiments i n the early 1960s studied the grasshopper or locust and showed that the timing o f the animal's w i n g beat i n f l i g h t depended o n a r h y t h m i c p a t t e r n generator. E v e n w h e n the sensory nerves were cut, the nervous system by itself c o u l d generate the o u t p u t w i t h n o sensory i n p u t ; h o w ever, the w i n g beat was slowed ( 2 0 ) . This suggested t h a t m o v e m e n t is possible i n the absence o f reflexive action. Sensory i n p u t , w h i l e n o t essential i n d r i v i n g m o v e m e n t , has an i m p o r t a n t f u n c t i o n i n m o d u l a t i n g action. These conclusions were f u r t h e r supported by w o r k e x a m i n i n g l o c o m o t i o n i n cats ( 2 1 ) . T h e results o f these experiments showed t h a t i n the cat, spinal neural networks c o u l d p r o d u c e a l o c o m o t o r r h y t h m w i t h o u t either sensory inputs o r descending patterns f r o m the b r a i n . By c h a n g i n g the intensity o f s t i m u l a t i o n t o the spinal c o r d , the animal c o u l d be made t o w a l k , t r o t , o r gallop. T h u s , i t was again s h o w n that reflexes d o n o t drive action, b u t t h a t central p a t t e r n generators by themselves can generate such complex movements as the w a l k , t r o t , and gallop. F u r t h e r experiments showed the i m p o r t a n t m o d u l a t o r y effects o f i n c o m i n g sensory inputs o n the central p a t t e r n generator ( 2 2 ) . These experiments l e d t o the m o t o r p r o g r a m t h e o r y o f m o t o r c o n t r o l . This t e r m has been used i n a n u m b e r o f ways by different researchers, so care s h o u l d be taken i n determ i n i n g h o w the t e r m is being used. T h e t e r m m o t o r p r o g r a m may be used t o i d e n t i f y a central p a t t e r n generator ( C P G ) , that is, a specific neural circuit like t h a t f o r generating w a l k i n g i n the cat. I n this case the t e r m represents neural connections t h a t are stereotyped and h a r d w i r e d . B u t the t e r m m o t o r p r o g r a m is also used to describe the h i g h e r level m o t o r programs that represent actions i n m o r e abstract terms.

A significant a m o u n t o f research i n the field o f psychology has supported the existence o f hierarchically organized m o t o r programs t h a t store the rules f o r generating movements so that we can p e r f o r m the tasks w i t h a variety o f effector systems.

ACTIVE

LEARNING

MODULE

maturation of neural

s normal

motor

: I T r roaches have i o n enhancing o r t i e s as an i m p o r mor c o n t r o l . T h e icve greater funcon o f reflex action, c s r - g a reflex apo o n t r o l is that sucis n o t alin functional :n the issue tactions instead o f

You can see this for yourself. Try writing your signature as you normally would on a small piece of paper. Now write it larger, on a blackboard. Now try it with your other hand. While you may be much more proficient with one hand versus the other, you will see elements of your signature that are common to all situations. As shown in Figure 1.7, the rules for writing your name are stored as a motor program at higher levels within the CNS. As a result, neural commands from these higher centers to write your name can be sent to various parts of the body. Yet, elements of the written signature remain constant regardless of the part of the body used to carry out the task (23).

LIMITATIONS T h e concept o f central p a t t e r n generators expanded o u r u n d e r s t a n d i n g o f the role o f the nervous system i n the c o n t r o l o f m o v e m e n t . H o w e v e r , we m u s t be careful t o realize t h a t the central p a t t e r n generator concept has never been i n t e n d e d t o replace the concept o f the importance o f sensory i n p u t i n c o n t r o l l i n g m o v e m e n t . I t simply expanded o u r u n d e r standing o f the flexibility o f the nervous system i n creating movements, t o i n c l u d e its ability t o create movements i n isolation f r o m feedback. A n i m p o r t a n t l i m i t a t i o n o f the m o t o r p r o g r a m concept is t h a t a central m o t o r p r o g r a m cannot be considered t o be the sole det e r m i n a n t o f action ( 2 3 ) . T w o identical c o m mands t o the e l b o w flexors, f o r example, w i l l p r o d u c e very different movements d e p e n d i n g o n w h e t h e r y o u r a r m is resting at y o u r side, o r i f y o u are h o l d i n g y o u r a r m o u t i n f r o n t o f y o u . T h e forces o f gravity w i l l act differently o n the l i m b i n the t w o c o n d i t i o n s , and thus

big Theories
B o f motor control fccHanding o f the from views o f c svstem and have : -: - o f actions r o t reactions. : been useful i n exs o f moveay o f v i e w i n g o n e can remove the B p u t ^ and still have 4 8 ) . I f w e re-

12

Section I

THEORETICAL FRAMEWORK

Abstract motor program

Synergy

Synergy

Synergy

Right hand muscles

Right arm muscles

Left hand muscles

Figure 1.7. Levels of control for motor programs and their output systems. Rules for action are represented at the highest level, in abstract motor programs. Lower levels of the hierarchy contain information essential for effecting action.

m o d i f y the m o v e m e n t . I n a d d i t i o n , i f y o u r muscles are f a t i g u e d , similar nervous system commands w i l l give very different results. T h u s , the m o t o r p r o g r a m concept does n o t take i n t o account the fact t h a t the nervous syst e m m u s t take i n t o account b o t h m u s c u l o skeletal a n d e n v i r o n m e n t a l variables i n achieving movement control. CLINICAL IMPLICATIONS M o t o r p r o g r a m theories o f m o t o r c o n t r o l have a l l o w e d clinicians t o m o v e b e y o n d a reflex explanation f o r disordered m o t o r c o n t r o l . Explanations f o r a b n o r m a l m o v e m e n t have been expanded t o i n c l u d e p r o b l e m s res u l t i n g f r o m abnormalities i n central p a t t e r n generators, o r i n h i g h e r level m o t o r p r o grams. M r s . Johnson, o u r stroke p a t i e n t , may i n d e e d have flexor spasticity i n her arms w h i c h may affect her ability t o m o v e . H o w e v e r , i t w i l l be i m p o r t a n t t o determine w h a t levels o f m o t o r p r o g r a m m i n g are i n v o l v e d . I f her higher levels o f m o t o r p r o g r a m m i n g are n o t affected, she w i l l be able t o c o n t i n u e t o use such programs as h a n d w r i t i n g , b u t w i l l f i n d alternate effectors, f o r example, her unaffected h a n d , t o carry o u t the tasks. O f course, these less used l o w e r level synergy a n d muscular systems w i l l have t o be t r a i n e d t o carry o u t these h i g h e r level p r o g r a m s .

I n patients whose h i g h e r levels o f m o t o r p r o g r a m m i n g are affected, m o t o r p r o g r a m t h e o r y suggests the i m p o r t a n c e o f h e l p i n g patients relearn the correct rules f o r a c t i o n . I n a d d i t i o n , t r e a t m e n t s h o u l d focus o n retraini n g movements i m p o r t a n t t o a f u n c t i o n a l task, n o t just o n reeducating specific muscles i n isolation.

Systems Theory
Even before m o t o r p r o g r a m concepts were developed, another researcher, N i c o l a i Bernstein ( 1 8 9 6 - 1 9 6 6 ) , a Russian scientist, was l o o k i n g at the nervous system a n d b o d y i n a w h o l e n e w way. Previous n e u r o p h y s i o l ogists h a d focused p r i m a r i l y o n neural c o n t r o l aspects o f m o v e m e n t . Bernstein recognized t h a t y o u cannot u n d e r s t a n d the neural c o n t r o l o f m o v e m e n t w i t h o u t an u n d e r s t a n d i n g o f the characteristics o f the system y o u are m o v i n g , a n d the external a n d i n t e r n a l forces acting o n the b o d y . I n describing the characteristics o f the system b e i n g m o v e d , he l o o k e d at the w h o l e b o d y as a mechanical system, w i t h mass, a n d subject t o b o t h external forces, like gravity, and i n t e r n a l forces, i n c l u d i n g b o t h inertial and m o v e m e n t - d e p e n d e n t forces. D u r i n g the course o f any m o v e m e n t the a m o u n t s o f force acting o n the b o d y w i l l change as p o t e n t i a l and kinetic energy change. H e thus showed

Chapter One

THEORIES OF M O T O R C O N T R O L

13

that the same central c o m m a n d c o u l d result i n q u i t e different mo ve me nt s because o f the interplay between external forces a n d variations i n the i n i t i a l c o n d i t i o n s ( 2 3 ) . F o r the same reasons, different c o m m a n d s c o u l d result i n the same m o v e m e n t . Bernstein also suggested t h a t c o n t r o l o f i nt e gra t e d m o v e m e n t was p r o b a b l y d i s t r i b u t e d t h r o u g h o u t m a n y i n t e r a c t i n g systems w o r k i n g cooperatively t o achieve m o v e m e n t . This gave rise t o the concept o f a model of motor control. distributed

T h u s , Bernstein believed t h a t synergies play an i m p o r t a n t role i n solving the degrees o f f r e e d o m p r o b l e m . T h i s is achieved by c o n straining certain muscles t o w o r k t o g e t h e r as a u n i t . H e hypothesized t h a t t h o u g h there are few synergies, they make possible almost the w h o l e variety o f movements w e k n o w . F o r example, he considered some simple synergies t o be the l o c o m o t o r , p o s t u r a l , a n d respiratory synergies. LIMITATIONS W h a t are the l i m i t a t i o n s o f Bernstein's systems approach? As y o u can see, i t is the broadest o f the approaches w e have discussed thus far, a n d since i t takes i n t o account n o t o n l y the c o n t r i b u t i o n s o f the nervous system t o a c t i o n , b u t also the c o n t r i b u t i o n s o f the muscle a n d skeletal systems, as w e l l as the forces o f gravity a n d i n e r t i a , i t predicts actual behavior m u c h better t h a n previous theories. H o w e v e r , as i t is presented today, i t does n o t focus as heavily o n the i n t e r a c t i o n o f the organism w i t h the e n v i r o n m e n t , as d o some other theories o f m o t o r c o n t r o l . CLINICAL IMPLICATIONS T h e systems t h e o r y has a n u m b e r o f i m plications f o r therapists. First, i t stresses the i m p o r t a n c e o f u n d e r s t a n d i n g the b o d y as a mechanical system. M o v e m e n t is n o t solely d e t e r m i n e d by the o u t p u t o f the nervous system, b u t is the o u t p u t o f the nervous system as f i l t e r e d t h r o u g h a mechanical system, the

H o w does Bernstein's approach t o m o t o r c o n t r o l d if f e r f r o m the reflex, hierarchical, or m o t o r p r o g r a m approaches presented previously? Bernstein asked questions a b o u t the organism, i n a c o n t i n u o u s l y c h a n g i n g situation. H e f o u n d answers that were different f r o m previous researchers a b o u t the nature and cause o f m o v e m e n t , since he asked different questions, such as: H o w does the b o d y as a mechanical system influence the c o n t r o l process? H o w d o the i n i t i a l c o n d i t i o n s affect the properties o f the movement? I n describing t he b o d y as a mechanical system, Bernstein n o t e d that w e have m a n y degrees o f f r e e d o m t h a t need t o be cont r o l l e d . F o r example, w e have m a n y j o i n t s , all o f w h i c h flex o r e x t e n d a n d m a n y o f w h i c h tam concepts can be r o t a t e d as w e l l . T h i s complicates m o v e m e n t c o n t r o l i n c r e d i b l y . H e said, " C o o r d i n a t i o n o f m o v e m e n t is the process o f masteri n g the r e d u n d a n t degrees o f f r e e d o m o f the m o v i n g o r g a n i s m " ( 2 3 ) . I n other w o r d s , i t involves c o n v e r t i n g the b o d y i n t o a c o n t r o l lable system. As a s o l u t i o n t o t he degrees of problem, freedom Bernstein hypothesized t h a t hierarBcber, N i c o l a i an scientist, cm a n d b o d y eorophysiolcontrol SB recognized of coral control icr-:ir.i:ng
I T C C ire mov-

b o d y . W h e n w o r k i n g w i t h the patient w h o has a central nervous system deficit, the therapist m u s t be careful t o assess the c o n t r i b u tion o f i m p a i r m e n t s i n the musculoskeletal system, as w e l l as the neural system, t o overall loss o f m o t o r c o n t r o l . I n o u r example o f M r s . J o h n s o n , the l o n g - t e r m loss o f m o b i l i t y i n her a r m a n d leg w i l l p o t e n t i a l l y affect the musculoskeletal system. kle She may show s h o r t e n i n g o f the e l b o w j o i n t . These musculoskeletal l i m i t a t i o n s flexors a n d loss o f range o f m o t i o n at the anw i l l have a significant effect o n her a b i l i t y t o recover m o t o r c o n t r o l .

chical c o n t r o l exists t o s i m p l i f y the c o n t r o l o f the body's m u l t i p l e degrees o f f r e e d o m . I n this way, the h i g h e r levels o f the nervous system activate l o w e r levels. T h e l o w e r levels ac: an ate synergies, or groups o f muscles t h a t are as a u n i t . We The t h i n k o f o u r m o v e m e n t repertoire like up o f many words. the the are the the w o r d s are muscles; synergies, themconstrained t o act t o g e t h e r sentences made letters w i t h i n the and words the

i . - r:es acting ztrz -ties ot the z r. zr.t w h o l e *rz~. mass, and s . Like gravity, I b o t h inertial :_T u r i n g the o u n t s o f force pe as p o t e n t i a l ie thus showed

themselves

sentences are

actions

selves.

14

Section I

THEORETICAL FRAMEWORK

T h e systems t h e o r y suggests t h a t assessm e n t and t r e a t m e n t m u s t focus n o t o n l y o n the i m p a i r m e n t s w i t h i n i n d i v i d u a l systems c o n t r i b u t i n g t o m o t o r c o n t r o l , b u t the effect o f interacting impairments among multiple systems. A g o o d example o f this i n M r s . J o h n son is the i n t e r a c t i n g i m p a i r m e n t s i n the musculoskeletal and neuromuscular systems that constrain her ability t o m o v e her a r m .

W h a t is nonlinear behavior? I t is a situation i n w h i c h , as one parameter is altered and reaches a critical value, the system goes i n t o a w h o l e n e w behavior p a t t e r n . F o r example, as an ani m a l walks faster and faster, there is a p o i n t at w h i c h , suddenly, i t shifts i n t o a t r o t . As the animal continues t o m o v e faster, there is a seco n d p o i n t at w h i c h i t shifts i n t o a gallop. This is s h o w n i n Figure 1.8. T h e dynamical action approach does n o t seek t o explain these shifts i n terms o f the nervous system c i r c u i t r y , b u t instead simply attempts t o describe mathematically the function o f these systems. This allows the prediction o f the ways t h a t a given system w i l l act i n different situations. O n e o f the p o i n t s t h a t p r o p o n e n t s o f this perspective p u t f o r t h is t h a t many b o d y m o v e m e n t transitions may be explainable w i t h o u t i n v o k i n g a specific neural p a t t e r n generator t o cause the t r a n s i t i o n . T h e transitions instead may be due t o the oscillat o r y o r p e n d u l u m - l i k e properties o f the l i m b s themselves. T h u s , the dynamical action perspective has deemphasized the n o t i o n o f c o m mands f r o m the central nervous system i n c o n t r o l l i n g m o v e m e n t and has s o u g h t physical explanations t h a t may c o n t r i b u t e t o m o v e m e n t characteristics as w e l l ( 2 8 ) . T h e dynamical action t h e o r y has recently been m o d i f i e d t o incorporate many o f Bernstein's concepts. This has resulted i n the b l e n d i n g o f these t w o theories o f m o t o r c o n t r o l i n t o a dynamical systems m o d e l ( 2 4 ) . This m o d e l suggests t h a t m o v e m e n t underl y i n g a c t i o n results f r o m the i n t e r a c t i o n o f b o t h physical a n d neural c o m p o n e n t s ( 2 9 ) . LIMITATIONS T h i s approach has added t o o u r understanding o f the elements c o n t r i b u t i n g t o m o v e m e n t itself, and serves as a r e m i n d e r t h a t u n d e r s t a n d i n g the nervous system i n isolation w i l l n o t allow the p r e d i c t i o n o f m o v e m e n t . H o w e v e r , a l i m i t a t i o n o f this m o d e l can be the p r e s u m p t i o n t h a t the nervous system has a fairly u n i m p o r t a n t r o l e , and t h a t the relationship between the physical system o f the animal and the e n v i r o n m e n t i n w h i c h i t o p erates p r i m a r i l y determines the animal's be-

Dynamical Action Theory

T h e dynamical action t h e o r y approach t o m o t o r c o n t r o l has b e g u n t o l o o k at the m o v i n g person f r o m a n e w perspective ( 2 4 2 6 ) . T h e perspective comes f r o m the broader study o f dynamics o r synergetics w i t h i n the physical w o r l d , and asks the questions: H o w d o the patterns and o r g a n i z a t i o n w e see i n the w o r l d c o m e i n t o b e i n g f r o m t h e i r orderless constituent parts? A n d , h o w d o these systems change over time? F o r example, w e have thousands o f muscle cells i n the heart t h a t w o r k together t o make the heart beat. H o w is this system o f thousands o f degrees o f freed o m (each cell w e add contributes a n e w degree o f f r e e d o m t o the system) reduced t o one o f few degrees o f f r e e d o m , so t h a t all the cells f u n c t i o n as a unit? T h i s p h e n o m e n o n , w h i c h w e see n o t o n l y i n heart muscle, b u t i n the patterns o f c l o u d f o r m a t i o n s and the patterns o f m o v e m e n t o f water as i t goes f r o m ice t o l i q u i d t o b o i l i n g t o evaporation, illustrates the principle o f self-organization, w h i c h is a f u n d a m e n t a l dynamical systems p r i n c i p l e . I t says that w h e n a system o f i n d i v i d u a l parts comes together, its elements behave collectively i n an o r d e r e d way. There is n o need for a " h i g h e r " center issuing instructions o r commands t o achieve c o o r d i n a t e d action. T h i s principle applied t o m o t o r c o n t r o l suggests t h a t m o v e m e n t emerges as a result o f i n t e r a c t i n g elements, w i t h o u t the need f o r specific c o m m a n d s , o r m o t o r programs w i t h i n the nervous system. T h e dynamical action o r synergetics perspective also tries t o find mathematical descriptions o f these self-organizing systems. C r i t i c a l features t h a t are examined are w h a t are called the nonlinear properties o f the system ( 2 7 ) .

Chapter One

THEORIES OF M O T O R C O N T R O L

15

tarnation in
i ir_c

BSD a whole Ar as an anEB a point at

Velocity

n r x A s the Baere ts i sec

t

aflop. T h i s c r : . : ; r . does i tcrrr.s or the srmply me runcH the predicBcm will act i n c points that at forth is that u s may be ex- / ipcdnc neural gansition. T h e o the oscillacs o f the limbs al action perGallop Behavioral state Walk Trot

Figure 1.8. A dynamical action model predicts discrete changes in behavior resulting from changes in the linear dynamics of a moving system. For example, as velocity increases linearly, a threshold is reached that results in a change in behavioral state of the moving animal from a walk, to a trot, and a gallop.

BMoo o f c o m ons system i n n o u g h t physiBxnx t o move-

havior. T h e focus o f the dynamical action theory is usually at the level o f this interface, n o t at u n d e r s t a n d i n g the neural c o n t r i b u t i o n s t o the system. CLINICAL IMPLICATIONS O n e o f the major implications o f the dynamical a c t i o n t h e o r y is the v i e w t h a t movem e n t is an emergent p r o p e r t y . T h a t is, i t emerges f r o m the i n t e r a c t i o n o f m u l t i p l e elements t h a t self-organize based o n certain d y namical properties o f the elements t h e m selves. T h i s means t h a t shifts o r alterations i n m o v e m e n t behavior can o f t e n be explained i n terms o f physical principles rather t h a n necessarily i n terms o f neural structures. W h a t are the implications o f this f o r treating m o t o r d y s c o n t r o l i n patients? I f as clinicians w e u n d e r s t o o d m o r e a b o u t the physical o r dynamical properties o f the h u m a n b o d y , we c o u l d make use o f these properties in h e l p i n g patients t o regain m o t o r c o n t r o l . For example, velocity can be an i m p o r t a n t c o n t r i b u t o r t o the dynamics o f m o v e m e n t . O f t e n , patients are asked t o move slowly i n an effort t o m o v e safely. Yet, this approach t o retraining fails t o take i n t o account the interaction between speed a n d physical properties o f the b o d y , w h i c h p r o d u c e m o m e n t u m , and

ibeorv has reorate many o f

therefore can help a weak patient m o v e w i t h greater ease. I n o u r example o f M r s . J o h n s o n , m o v i n g slowly may n o t be the best strategy f o r g e t t i n g f r o m sit t o stand, i f weakness is a p r i mary i m p a i r m e n t . Instead, teaching her t o i n crease the speed o f t r u n k m o t i o n m a y allow her t o generate sufficient m o m e n t u m t o succeed i n standing.

, resulted i n the
t o t motor conp model ( 2 4 ) . Bomcnt under: interaction o f

Parallel Distributed Processing Theory

The parallel d i s t r i b u t e d processing ( P D P ) t h e o r y o f m o t o r c o n t r o l describes h o w the nervous system processes i n f o r m a t i o n f o r action. T h i s t h e o r y has been used t o explain h o w we acquire n e w skills, since i t makes predictions about the processes used by the nervous system d u r i n g the development o r acq u i s i t i o n o f n e w skills ( 3 0 ) . T h e P D P t h e o r y is consistent w i t h current k n o w l e d g e i n n e u r o p h y s i o l o g y t h a t the nervous system operates b o t h t h r o u g h serial processing, that is, processing i n f o r m a t i o n t h r o u g h a single pathway, and t h r o u g h parallel processing, t h a t is, processing i n f o r m a tion t h r o u g h m u l t i p l e pathways t h a t process the same i n f o r m a t i o n simultaneously i n different ways ( 3 1 ) .

orients ( 2 9 ) .

A to o u r underrjrjritnbuting t o i i reminder that B e r n in isolation B of movement. B m o d e l can be procs svstem has :o m i : me relaa i system o f the t in which it opthe animal's be-

16

Section I

THEORETICAL FRAMEWORK

Figure 1.9. Parallel distributed processing model showing three layers, the input, hidden, and output layers, hypothetically equivalent to sensory, interneuron, and motor units.

Input units

Hidden units

Output units

Scientists have b e g u n t o m o d e l neural processing u s i n g c o m p u t e r programs. These programs have been developed w i t h sophisticated circuitry similar t o brain n e t w o r k s . T h i s is h o w t h e m o d e l i n g is d o n e : M o d e l s consist o f elements t h a t are h o o k e d t o g e t h e r i n circuits. L i k e n e u r o n a l synapses, each elem e n t can be affected i n a positive o r negative way by the o t h e r elements. A l s o , like n e u r o n a l synaptic transmission, each element can have different magnitudes o f either positive o r negative effect o n the next element. Each element t h e n summates all t h e i n c o m i n g positive a n d negative i n p u t s . These models have been made i n t o layered n e t w o r k s c o n t a i n i n g i n p u t elements, intermediate processing layers called h i d d e n layers, a n d o u t p u t elements. T h i s is s h o w n i n Figure 1.9. These layers are equivalent t o sensory neurons, i n t e r n e u r o n s , and m o t o r neurons ( 3 0 ) . Just as i n the nervous system, t h e efficiency o f performance i n this system depends o n t w o factors. T h e first is t h e p a t t e r n o f c o n nections between t h e layers, a n d t h e second is t h e s t r e n g t h o f i n d i v i d u a l connections. T h e beauty o f this m o d e l is t h a t the researcher can determine t h e m o s t efficient connections t o p e r f o r m a particular f u n c t i o n t h r o u g h a techn i q u e called back propagation. T h r o u g h the process o f back p r o p a g a t i o n , t h e m o s t efficient o u t p u t f r o m t h e " m o t o r n e u r o n " layer is d e t e r m i n e d . I t starts w i t h a r a n d o m set o f inputs t o t h e system. T h e system t h e n calculates the difference between t h e desired a n d the actual activity o f the o u t p u t u n i t . T h e dif-

ference between actual a n d desired activity is called t h e error. T h e error is used t o m o d i f y the connections a m o n g those elements that have p r o d u c e d t h e error. T h e process is r u n over a n d over, simu l a t i n g t h e r e p e t i t i o n o f a task p e r f o r m e d again a n d again. W i t h this activity, t h e system self-corrects u n t i l i t solves t h e o u t p u t p r o b lem. T h e m o d e l has correctly p r e d i c t e d p r o cesses i n b o t h perceptual a n d action systems. F o r example, a P D P has been used t o simulate the processing o f visual s t i m u l i u n d e r l y i n g the ability t o recognize a n d identify letters. I n add i t i o n , t h e models have been used t o predict h o w w e calculate t h e correct j o i n t angles associated w i t h m o v i n g a l i m b t o a particular p o s i t i o n i n space ( 3 1 ) . P D P is somewhat u n i q u e i n its emphasis o n explaining neural mechanisms associated w i t h m o t o r c o n t r o l . T h i s t h e o r y a n d its related models are o f great interest r i g h t n o w because, t h o u g h they are n o t exact replicas o f the nervous system, t h e y have m a n y o f t h e properties t h a t are also seen i n t h e nervous system. T h u s , they m a y help us understand h o w t h e nervous system solves particular movement problems. LIMITATIONS T h i s t h e o r y is n o t i n t e n d e d t o be an exact replica o f the nervous system, a n d therefore m a n y o f its f u n c t i o n s , such as back p r o p agation, d o n o t m i m i c nervous system

Chapter One

T H E O R I E S OF M O T O R C O N T R O L

17

p H O B f

of

information

during

perfor-

mamac a n d learning. vKAL IMPLICATIONS T l i c P D P t h e o r y is relatively n e w , a n d . j r i c a l applications are relatively u n I W I I L T h e r e are several ways t h a t P D P m o d : r r e g r a t e d i n t o clinical practice. : del c o u l d be used t o p r e d i c t mmm anrcrv within the nervous system affects faaJOL T h e t h e o r y predicts t h a t because o f 3 K a n i a b i l i r v o f parallel r e d u n d a n t p a t h B E T L r r e loss o f just a few elements w i l l n o t izz'z;: r u n c t i o n . H o w e v e r , the the-acx p r e d i c t that once a certain level o r stmanwkA is attained, the loss o f a d d i t i o n a l elg r - i f * , w i l l affect the capacity o f the system H T W I T h i s concept o f a t h r e s h o l d f o r a r r ~ ; i r . re seen i n many cases o f pan u c 0 ; . F o r example, i n Parkinson's disease . jsarirtal loss o f cells i n the basal gan- ; i r . r r o m s may n o t be apparent murrain a r i l the n u m b e r o f neurons lost TESkrae* a critical t h r e s h o l d . H i ihaul m i pathways suggest the possi:.r.e roads t o recovery; thus, the re used to suggest approaches i - i i m i f m o t o r d y s c o n t r o l . I t suggests Tear. MJUJMJ> m i g h t be best w h e n rehabilita3DK wammmg. is applied t o m u l t i p l e pathways. War cii.~s t M r s . lohnson's r e h a b i l i t a t i o n a gr.r .relude b o t h voluntary' acti: r i - : r r n e m i u s muscle t o help : ~ - : : strength, b u t also practice, -roc muscle i n postural and l o c o m o t o r

t h e o r y o f tasks. B y tasks, Greene was referring t o the f u n d a m e n t a l problems that the C N S was r e q u i r e d t o solve i n order t o accomplish m o t o r tasks. A c c o r d i n g t o Greene, an example o f a f u n d a m e n t a l task inherent i n m o t o r c o n t r o l is the degrees o f f r e e d o m p r o b l e m described by Bernstein. A c c o r d i n g t o Greene, a t h e o r y o f tasks w o u l d help neuroscientists f i n d observable behaviors t o measure t h a t are relevant t o the tasks the b r a i n is called u p o n t o p e r f o r m . T h u s , an u n d e r s t a n d i n g o f m o t o r c o n t r o l requires m o r e t h a n an u n d e r s t a n d i n g o f circuits. I t requires an u n d e r s t a n d i n g o f the u n d e r l y i n g problems the C N S is r e q u i r e d t o solve i n order t o accomplish m o t o r tasks. A task-oriented approach t o the study o f m o t o r c o n t r o l w o u l d p r o v i d e the basis f o r a m o r e coherent picture o f the m o t o r system. Greene suggests that once the essentials o f a task have been organized i n t o a coherent p i c t u r e , i t becomes possible t o k n o w less and understand m o r e . A n adaptation o f Greene's t h e o r y o f tasks has been elaborated b y G o r d o n ( 3 3 ) a n d H o r a k ( 3 4 ) . T h e task-oriented approach presented by G o r d o n and H o r a k , however, defines task f r o m a m o r e f u n c t i o n a l perspective. T h a t is, w h a t c o n t r o l issues are inherent i n the accomplishment o f f u n c t i o n a l tasks i n meani n g f u l environments? T h e task-oriented approach is based o n the r e c o g n i t i o n that the goal o f m o t o r c o n t r o l is the c o n t r o l o f m o v e m e n t t o accomplish a particular task, n o t the elaboration o f m o v e m e n t f o r the sake o f m o v i n g alone (except i n unusual cases such as dance). T h e task-oriented approach assumes t h a t c o n t r o l o f m o v e m e n t is organized a r o u n d goal-directed f u n c t i o n a l behaviors such as w a l k i n g o r t a l k i n g . LIMITATIONS A l i m i t a t i o n o f a task-oriented t h e o r y o f m o t o r c o n t r o l is a lack o f consistent agreem e n t a b o u t w h a t the f u n d a m e n t a l tasks o f the C N S are. I n a d d i t i o n , scientists d o n ' t always agree o n w h a t the essential elements b e i n g c o n t r o l l e d w i t h i n a task are. F o r example, some scientists s t u d y i n g postural c o n t r o l believe that c o n t r o l l i n g head p o s i t i o n is the es-

Tisk Oriented Theories

se last 50 years, a tremendous r : r r i r o n o n the basic structure nas emerged f r o m neuroscience _: there is still the r e c o g n i t i o n that J W W M tat b u t understand very l i t t l e . T h a t rr m u c h about neural c i r c u i t r y , b u t e neurons operate t o g e t h e r - nc : r. ~ . r r Peter Greene ( 3 2 ) , a themtstLZL a o l o g i s t . suggested that w h a t was . d :c m o t o r c o n t r o l was a ..r

18

Section I

THEORETICAL FRAMEWORK

sential goal o f the postural system. H o w e v e r , other scientists s t u d y i n g postural c o n t r o l believe t h a t c o n t r o l l i n g center o f mass p o s i t i o n t o achieve b o d y stability is the essential goal o f postural c o n t r o l . CLINICAL IMPLICATIONS T h e m o s t significant i m p l i c a t i o n o f a task-oriented t h e o r y o f m o t o r c o n t r o l is the concept t h a t m o t o r r e t r a i n i n g needs t o focus o n essential f u n c t i o n a l tasks. I t suggests the importance o f u n d e r s t a n d i n g the role o f perceptual, cognitive, and action systems i n acc o m p l i s h i n g these tasks. O n e o f the challenges f o r clinicians is t o analyze essential components o f everyday tasks we are called u p o n t o r e t r a i n . T h i s requires m o r e t h a n an u n d e r s t a n d i n g o f the biomechanical features o f the task, t h a t is, the m o t o r strategies used t o accomplish the task. I t also requires u n derstanding the perceptual basis f o r action, and the cognitive c o n t r i b u t i o n s t o action. I n o u r example o f M r s . Johnson, w h a t are the essential tasks t h a t w i l l be retrained d u r i n g the course o f her recovery? H o w w i l l these tasks be retrained? H o w m u c h time w i l l the clinician spend o n r e t r a i n i n g f u n c t i o n , as opposed t o w o r k i n g o n some o f the essential elements c o n t r i b u t i n g t o f u n c t i o n , such as strength a n d range o f motion? H o w can the clinician ensure that tasks learned i n a clinical setting w i l l be retained w h e n M r s . Johnson finally returns t o her o w n home?

Figure 1.10. Ecological approach stresses the interaction between the individual and the environment. The individual actively explores the environment, which in turn supports the individual's actions.

ecological approach t o m o t o r c o n t r o l . I t suggests t h a t m o t o r c o n t r o l evolved so t h a t animals c o u l d cope w i t h the e n v i r o n m e n t a r o u n d t h e m , m o v i n g i n i t effectively i n order t o find f o o d , r u n away from predators, b u i l d shelter, and even play ( 2 8 ) . W h a t is n e w a b o u t this approach? I t was really the first time that researchers began focusing o n h o w actions are geared t o the e n v i r o n m e n t . A c t i o n s require perceptual i n f o r m a t i o n t h a t is specific t o a desired goal-directed action p e r f o r m e d w i t h i n a specific e n v i r o n m e n t . T h e o r g a n i z a t i o n o f action is specific t o the task and the e n v i r o n m e n t i n w h i c h the task is being p e r f o r m e d . Whereas m a n y previous researchers h a d seen the organism as a sensory-motor system, G i b s o n stressed t h a t i t was n o t sensation per se that was i m p o r t a n t t o the animal, b u t perc e p t i o n . Specifically, w h a t is needed is the perc e p t i o n o f e n v i r o n m e n t a l factors i m p o r t a n t t o the task. H e stated t h a t perception focuses o n detecting i n f o r m a t i o n i n the e n v i r o n m e n t t h a t w i l l support the actions necessary t o achieve the goal. F r o m an ecological perspective, i t is i m p o r t a n t t o determine h o w an organism detects i n f o r m a t i o n i n the e n v i r o n m e n t t h a t is relevant t o action, w h a t f o r m this i n f o r m a t i o n takes, and h o w this i n f o r m a t i o n is used t o m o d i f y and c o n t r o l m o v e m e n t ( 2 8 ) . I n summary, the ecological perspective has broadened o u r u n d e r s t a n d i n g o f nervous

Ecological Theory
I n the 1960s, i n d e p e n d e n t o f the research i n physiology, a psychologist n a m e d James G i b s o n was b e g i n n i n g t o explore the way i n w h i c h o u r m o t o r systems a l l o w us t o interact m o s t effectively w i t h the e n v i r o n m e n t i n order t o p e r f o r m goal-oriented behavior ( 3 5 ) . H i s research focused o n h o w we detect i n f o r m a t i o n i n o u r e n v i r o n m e n t t h a t is relevant t o o u r actions, and h o w we use this i n f o r m a t i o n t o c o n t r o l o u r movements (see F i g . 1.10). T h i s v i e w was expanded by the students o f G i b s o n ( 3 6 , 37) and became k n o w n as the

Chapter One

THEORIES OF M O T O R C O N T R O L

19

mnction f r o m t h a t o f a sensory-motor - g to environmental variables, K o f a perception-action system w h i c h m r l jres the e n v i r o n m e n t t o satisfy its

plete t h e o r y o f m o t o r c o n t r o l , the one that really predicts the nature and cause o f m o v e m e n t and is consistent w i t h o u r c u r r e n t k n o w l e d g e o f b r a i n anatomy and physiology? As y o u n o d o u b t can already see, there is n o one t h e o r y that has i t all. W e believe the best theory o f m o t o r c o n t r o l is one t h a t c o m bines elements f r o m all o f the presented theories. A comprehensive, o r i n t e g r a t e d , t h e o r y recognizes the elements o f m o t o r c o n t r o l we d o k n o w about and leaves r o o m f o r the things we d o n ' t . A n y current t h e o r y o f m o t o r c o n t r o l is i n a sense unfinished, since there m u s t always be r o o m t o revise a n d incorporate n e w information. M a n y people have been w o r k i n g t o develop an integrated t h e o r y o f m o t o r c o n t r o l ( 2 4 , 34, 3 8 ^ 3 ) . I n some cases, as theories are m o d i f i e d , n e w names are applied. As a result, i t becomes d i f f i c u l t t o distinguish a m o n g evolving theories. For example, systems, d y namical, dynamical action, and dynamical action systems are all terms that are o f t e n used interchangeably. I n previous articles we ( 4 0 , 4 2 ) have called the t h e o r y o f m o t o r c o n t r o l o n w h i c h we base o u r research and clinical practice a systems approach. W e have c o n t i n u e d t o use this name, t h o u g h o u r concept o f systems theory differs f r o m Bernstein's systems t h e o r y and has evolved t o incorporate m a n y o f the concepts proposed b y o t h e r theories o f m o t o r c o n t r o l . I n this b o o k w e w i l l c o n t i n u e t o refer t o o u r t h e o r y o f m o t o r c o n t r o l as a systems approach. This approach argues that i t is critical t o recognize t h a t m o v e m e n t emerges f r o m an i n t e r a c t i o n between the i n d i v i d u a l , the task, and the e n v i r o n m e n t i n w h i c h the task is b e i n g carried o u t . T h u s , m o v e m e n t is n o t solely the result o f muscle-specific m o t o r programs, o r stereotyped reflexes, b u t results f r o m a dynamic interplay between perceptual, cognitive, and action systems. A c t i o n systems are defined here t o i n clude b o t h the neuromuscular aspects and the physical o r dynamic properties o f the musculoskeletal system itself. T h e organizational properties o f the system emerge as a f u n c t i o n o f the task and the e n v i r o n m e n t i n w h i c h the task is p e r f o r m e d .

^C7A~OXS A d m o u g h the ecological approach has m : : i : _r 1-mowledge significantly con- -z interaction o f the organism and t , i t has t e n d e d t o give less t o the o r g a n i z a t i o n and f u n c t i o n o f system, w h i c h l e d t o this inters' the research emphasis has the nervous system t o the organn t interface. IMPLICATIONS -. - L :: : D.ntribution o f this view is i n me individual as an active explorer : - nment. T h e active e x p l o r a t i o n o f tu ( ; - ; me e n v i r o n m e n t i n w h i c h the p e r f o r m e d allows the i n d i v i d u a l t o dec ways t o accomplish a task. is i m p o r t a n t n o t o n l y i n the way movements t o accomplish a task, me way we use o u r senses d u r i n g

-s

- r m i n t part o f treatment is helpo h n s o n explore the possibilities f o r mmm, i f u n c t i o n a l task i n m u l t i p l e ways. develop m u l t i p l e adaptive so- : _ : : m p d s h i n g a task requires that s e n t explore a range o f possible ways t o - ~ . . - - i task, and discover the best so fcr t h e m , given the patient's set o f l i m ns.. I n M r s . Johnson's case, this ability t o rjsoorcr a range o f solutions is h a m _ reduced ability t o m o v e , inaccurate y m n v . a n d possible cognitive lirnita-

H THEORY OF M O T O R CONTROL I S BEST?

n s me : * h k h m o t o r c o n t r o l t h e o r y best current theoretical a n d practice .-mists? W h i c h is the m o s t c o m -

20

Section I

THEORETICAL

FRAMEWORK

T h i s theoretical f r a m e w o r k w i l l be used t h r o u g h o u t this text, and is the basis f o r c l i n ical methods f o r assessing and treating m o t o r d y s c o n t r o l i n the patient w i t h neurological problems. W e have f o u n d the t h e o r y useful i n h e l p i n g us t o generate research questions and hypotheses a b o u t the nature and cause o f movement.

2.

3.

4.

SUMMARY
1. The study of motor control is the study of the nature and cause of movement. It deals with both stabilizing the body in space, that is, postural and balance control, and with moving the body in space. The specific practices used to assess and treat the patient with motor dyscontrol are determined by underlying assumptions about the nature and cause of movement that come from specific theories of motor control. A theory of motor control is a group of abstract ideas about the nature and cause of movement. Theories provide: (a) a framework for interpreting behavior; (b) a guide for clinical action; (c) new ideas; and id) working hypotheses for assessment and treatment. Rehabilitation practices reflect the theories, or basic ideas, we have about the cause and nature of function and dysfunction. In this chapter we have reviewed many motor control theories that have an impact on our perspective regarding assessment and treatment, including the reflex theory, hierarchical theory, motor programming theories, systems theory, dynamical action theory, parallel distributed processing theory, task-oriented theories, and ecological theory. In this text we use our systems theory approach as the foundation for many clinical applications. According to this theory, movement arises from the interaction of multiple processes, including (a) perceptual, cognitive, and motor processes within the individual, and (h) interactions between the individual, the task, and the environment.
v

5.

6.

2.

7.

3.

8.

4.

9. 10.

5.

11.

12. 13.

6.

14.

15.

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T H E O R I E S OF M O T O R C O N T R O L

21

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