Examin@ion of M"r Function:

- The central concept is that many systems interact to produce

coordinated movement, not just the nervous system.
M"r Control and M"r Learning

Motor control evolves from a complex set of neural, physical, Cognition (attention, memory, learning, judgment, and decision
and behavioral processes that govern posture and movement. making) and perception (interpretation of sensation) are also critical.

motor skills are learned through interaction and exploration of - Impairments in any of these interacting systems can significantly
alter the quality of the movement produced and the level of
the environment
function achieved

Practice and feedback are important variables in defining

units of the central nervous system (CNS) are organized around
motor learning and motor skill development.
specific task demands (termed task systems).

Sensory information about movement is used to guide and

CNS may be necessary for complex tasks, whereas only small
shape the development of motor programs.
portions may be needed for simple tasks.

motor program is defined as “an abstract representation that,

- The CNS organizes and integrates vast amounts of sensory
when initiated, results in the production of a coordinated movement
information.
sequence.”

Lateral pathways are involved in voluntary movement of distal

Higher-level motor programs can be viewed as abstract
musculature and are under direct cortical control
rules or code for coordinated actions that are stored (generalized
motor programs [GMPs])
Examples: corticospinal and rubrospinal tracts

GMPs contain information about the order of events, the timing of

Ventromedial pathways are involved in control of posture
events (temporal structure), the overall force of contractions, and
and locomotion and are under brainstem control
the muscle(s) or limb(s) used in the movements.

Examples: vestibulospinal tracts, tectospinal tract, and pontine and

Sensory feedback from the responding limbs, as well as from
medullary reticulospinal tracts
the environment, modifies the resulting movements.

neurons of the ventral horn of the spinal cord are the final
motor plan (complex motor program) is an idea or plan for
common pathway to engage the peripheral muscles for function.
purposeful movement that is made up of several component motor
programs.
Motor skills are acquired and modified by actions of the CNS
through processes of motor learning.
Motor memory (procedural memory) involves the recall of
motor programs or subroutines
Motor learning is defined as “a set of internal processes
includes information on: associated with practice or experience leading to rela- tively
permanent changes in the capability for skilled behavior.”
(1) initial movement conditions
Feedback is response-produced information received during or
(2) how the movement felt, looked, and sounded after the movement and is used to monitor output for corrective
(sensory consequences) actions.

(3) specific movement parameters (knowledge of
performance)
(4) outcome of the movement (knowledge of
results).
systems theory defines cooperative actions of multiple systems
allow for accommodation of movement to match the specific
demands of the task and the environment
Feedforward the sending of signals in advance of movement to
ready the sensorimotor systems, allows for anticipatory adjustments
in postural activity
- Processing of information by the CNS is both serial and
parallel, leading to the production of coordinated movement.
Coordination is the ability to execute smooth, accurate, and
controlled motor responses.

- distributed model of motor control. Coordinative structures (synergistic units) are the functionally
specific units of muscles that are constrained by the nervous
system to act cooperatively to produce relatively stable movement
patterns but are scaled to the environment.
Recovery of function is the reacquisition of movement skills
lost through injury
- A determination then needs to be made as to whether the
movements are of sufficient quality and efficiency to permit return
of function
Compensation refers to the adoption of alternative behavioral
strategies to complete a task.
neuroplasticity refers to the ability of the brain to change and
repair itself.
- Neuroplasticity includes “a continuum from short-term changes in
the efficiency or strength of synaptic connections to long-term
structural changes in the organization and numbers of connections
among neurons.”
- As learning progresses there is a shift from short-term to long-
term memory processes.
Memory allows for continued access of this information for
repeat performance or modification of existing patterns of
movement.
Damage to the CNS interferes with motor function
processes.
- Lesions affecting areas of the CNS can produce specific,
recognizable deficits that are consistent among patients
- Individual differences in neural plasticity, recovery, and functional
outcomes can be expected.
- resultant problems in motor function are numerous, complex, and
difficult to delineate.
The comprehensive examination focuses on delineation
of impairments, activity limitations, and participation restrictions.
- Those impairments that directly affect motor function and motor
learning should be clearly identified.
- Anticipated goals, expected outcomes, and plan of care (POC) can
then be effectively developed.
COMPONENTS OF THE EXAMIN$ION
- sometimes screening examinations reveal problems in
(1) patient history
(2) a review of relevant systems
(3) specific tests and measures that allow formulation of the
diagnosis, prognosis, and POC
Patient History
During the patient/client history, information is gathered on
(1) general demographics
(2) social history
(3) employment/work (job/school/play)
(4) living environment
(5) general health status
(6) social/health habits
(7) family history
(8) medical/surgical history
(9) current condition(s)/chief complaint(s)
(10) functional status and activity level
(11) medications
(12) other clinical tests. Information is obtained from the patient and
other interested persons (family members, significant others, and
caregivers).
- If the patient is unable to communicate accurate and meaningful
information, as is frequently the case with injury to the brain, data
must be gathered from other sources
The International Classification of Functioning,
Disability and Health (ICF) model, focusing on
impairments, activity limitations, and participation restrictions, provides
a useful framework
Systems Review
- serves the purpose of a screening examination; that is, a brief or
limited examination of body systems.
- identify potential problems that will require more extensive testing.
communication and/or cognition that preclude further testing.
- The therapist will document this in the medical record as
unable to test at the present time due to severe
communication/cognitive deficits.
Tests and Measures
- Specific parameters of dyscontrol should be closely examined
using appropriate tests and measures.
- If the test accurately measures the parameter of performance
being examined, it is said to have validity.
Validity can be established through construct, content, and
criterion based validity (concurrent, predictive, and prescriptive)
Reliability of an instrument is reflected in the consistency of
results obtained by a single examiner over repeat trials (intrarater
reliability) or among multiple examiners (interrater reliability).
Sensitivity refers to the proportion of times that a method of
analysis correctly identifies an abnormality as being present (true
positive)
Specificity refers to the proportion of times that a method of
analysis correctly identifies an abnormality as being absent (true
negative).
examination of motor function is a multifaceted process that
requires a number of different specific tests and measures
Quantitative instruments use objective measurement as a
way of examining performance.
Documentation constraints imposed by the health care system
and third-party payers increasingly emphasize objective instruments
as proof of the need for services and the effectiveness of services.
Reexaminations are performed to determine if goals and
outcomes are being met and if the patient is bene- fiting from the
plan of care (POC).
- Reexamination is also an important quality
assurance measure.
FAC%RS TH$ M& CONSTRAIN THE M'R FUNCTION
EXAMIN$ION
- The obtunded patient is difficult to arouse from sleeping and once
- Impairments in sensation and sensory integrity can also profoundly
influence a patient’s movement responses.
- Using tests and directions that confuse a patient during an
examination or are clearly beyond the capabilities of the patient will
only yield inaccurate information about a patient’s movement
behaviors.
Factors are: Consciousness and Arousal , Cognition, Sensory
Integrity and Integration, Joint Integrity, Postural Alignment, and
Mobility
Consciousness and Arousal
- Examination of consciousness and arousal is important in
determining the degree to which an individual is able to respond.
ascending reticular activating system (ARAS)
includes core neurons in the brainstem, the locus coeruleus, and
raphe nuclei that synapse directly on the thalamus, cortex, and other
brain regions.
- It functions to arouse and awaken the brain and control sleep–
wake cycles. High levels of activity are associated with extreme
excitement (high arousal), whereas lesions in the brainstem are
associated with sleep and coma
descending reticular activating system (DRAS) is
composed of the pontine and medullary reticulospinal tracts.
pontine (medial) reticulospinal tract enhances spinal
cord a antigravity reflexes and extensor tone of lower limbs.
medullary (lateral) reticulospinal tract has the opposite
effect, reducing antigravity control.
Five different levels of consciousness: Consciousness, lethargy,
obtunded state, stupor, coma
Consciousness refers to a state of arousal accompanied by
awareness of one’s environment.
- A conscious patient is awake, alert, and oriented to his or her
surroundings.
Lethargy refers to altered consciousness in which a person’s
level of arousal is diminished.
- The lethargic patient appears drowsy but when questioned can
open the eyes and respond briefly.
Obtunded state refers to diminished arousal and awareness.
aroused, appears confused.
- The patient responds slowly and demonstrates little interest in or
awareness of the environment.
- The therapist should shake the patient gently as if awakening
someone from sleep and again use simple questions.
Stupor refers to a state of altered mental status and
responsiveness to one’s environment.
- The patient can be aroused only with vigorous or unpleasant
stimuli
- The patient demonstrates little in the way of voluntary verbal or
motor responses.
- Mass movement responses may be observed in response to
painful stimuli or loud noises.
inverted-U principle (Yerkes- Dodson law) appropriate
level of arousal allows for optimal motor performance, very low or
high levels of arousal can cause deterioration in motor performance
ANS has two main divisions

coma The unconscious patient and cannot be aroused.
- The eyes remain closed and there are no sleep–wake cycles.
- The patient does not respond to repeated painful stimuli and
may be ventilator dependent.
- the actions of the ANS are typically widespread with multiple
systems engaged and two main divisions
sympathetic nervous system (SNS) allows actions to be
initiated to protect the individual during conditions of stress (the
alarm system)

- Reflex reactions may or may not be seen, depending on the - fight or flight responses
location of the lesion(s) within the CNS.
Parasympathetic nervous system (PNS) is activated
True coma is generally time limited. continuously to maintain homeostasis.

Patients emerge into a minimally conscious (vegetative) - It shuts down when the SNS is activated and works to restore
state, characterized by return of irregular sleep–wake cycles and homeostasis afterward
normalization of the so-called vegetative functions— respiration,
digestion, and blood pressure control. Critical components for baseline examination include:

persistent vegetative state is used to describe individuals (1) a representative sampling of ANS responses, including heart rate
who remain in a vegetative state 1 year or longer after TBI and 3 (HR), blood pressure (BP), respiratory rate (RR), pupil dilation, and
months or more for anoxic brain injury. sweating;

- This state is caused by severe brain injury. (2) a determination of patient reactivity, including the degree and
rate of response to stimulation
Glasgow Coma Scale (GCS) is a gold standard instrument
used to document level of consciousness in acute brain injury. (3) a determination of physiological stressors

Three areas of function are examined: eye opening, best motor

response, and verbal response.

The Rancho Los Amigos Scale, or Levels of

Cognitive Functioning (LOCF) is widely used in
rehabilitation facilities to examine the return of the person with brain
injury from coma (Level I, no response) to consciousness (Level VIII,
Purposeful–Appropriate).

Pupils that are bilaterally small may be indicative of damage

to the sympathetic pathways in the hypothalamus or metabolic
encephalopathy.

Pinpoint pupils are suggestive of a hemorrhagic pontine lesion

or narcotic overdose

Pupils that are fixed in mid-position and slightly dilated are

suggestive of midbrain damage, whereas large bilaterally fixed and
dilated pupils suggest severe anoxia or drug toxicity (e.g., tricyclic
antidepressants).

one pupil is fixed and dilated, temporal lobe herniation

with compression of the oculomotor nerve and midbrain is likely.
Cognition
- screening examination of cognitive abilities should include
orientation, attention, and memory; communication; and executive
or higher-order cognition
- Impaired cognitive function deficits can range from orientation and
memory deficits to poor judgment; distractibility; and difficulties in
information processing, abstract reasoning, and learning, to name
just a few.
- Patients with deficits across many or all areas of cognitive function
demonstrate diffuse or multifocal pathology
- Patients with deficits in only one or a few areas of testing typically
demonstrate focal deficits
Orientation
- is the ability to comprehend and to adjust oneself with regard to
time, location, and identity of persons.
It is examined with respect to:
(1) time (What day/month/season/year is it? What is the time of
day?)
(2) place (Where are you? What city/state are we in? What is the
name of this place?)
(3) person (What is your name? How old are you? Where were
you born? What is the name of your wife/husband?).
Findings are documented in the medical record as follows: Patient is
alert and oriented ︎ 3 (time, person, place) or ︎ 2 (person, place)
depending on the domains correctly identified.
Attention
- is the directing of consciousness to a person, thing, perception, or
thought.
- It is dependent on the capacity of the brain to process information
from the environment or from long-term memory.
- An individual with intact selective attention is able to screen
and process relevant sensory information about both the task and
the environment while screening out irrelevant information.
- Attention deficits are typically seen in individuals with delirium,
brain injury, dementia, mental retardation, or performance anxiety.
- Selective attention can be examined by asking
the patient to attend to a particular task. recall.
Sustained attention (or vig- ilance) is examined by
determining how long the patient is able to maintain attention on a
particular task (time on task).
Alternating attention (attention flexibility) is examined by
requesting the patient to alternate back and forth between two
different tasks
- Requesting the patient to perform two tasks simultaneously is
used to determine divided attention.
Memory
- is the process of registration, retention, and re- call of past
experience, knowledge, and ideas.
Declarative (explicit) memory involves the conscious
recollection of facts, past events, experiences, and places.
Motor memory (procedural memory) involves recall of
movements or motor information and storage of motor programs,
subroutines, or schema as well as perceptual and cognitive skills.
Immediate memory (immediate recall) refers to the
immediate registration and recall of information after an interval of a
few seconds
Short-term memory (STM) (recent memory) refers to
the capability to remember current, day-to-day events , learn new
material, and retrieve material after an interval of minutes, hours, or
days.
Long-term memory (LTM) (remote memory) refers to
the recall of facts or events that occurred years before (e.g.,
birthdays, anniversary, historic facts).
- It includes items an individual would be expected to know.
Mini-Mental Status Examination (MMSE) provides a valid
and reliable quick screen of cognitive function.
Patients with amnesia experience partial or total, permanent or
transient loss of memory
Anterograde amnesia (post-traumatic amnesia
[PTA]) refers to the inability to learn new material acquired after a
brain insult
Retrograde amnesia refers to the inability to remember
previous learning acquired before the occurrence of a brain insult.
delirium (acute confusional state) typically demonstrate
impairments in immediate memory and STM along with confusion,
agitation, disorientation, and usually illusions or hallucinations
dementia demonstrate broad-based memory impairments and
learning
- Patients who demonstrate difficulty in retrieving information will
often relate that the information is on the “tip of their tongue” (the
tip of the tongue phenomenon).
Communication
- The patient’s grasp of information and ability to communicate
should be ascertained.
Dysarthria- Problems with articulation
- speech errors, such as difficulties with timing, vocal quality, pitch,
volume, and breath control
Problems of fluency - word flow without pauses or breaks,
should be noted.
fluent aphasia - speech that flows smoothly but contains
errors, neologisms (nonsense words), misuse of words, and
circumlocutions (word substitution)
Example: Wernickes Aphasia
nonfluent aphasia - speech that is slow and hesitant with
Example: Brocas Aphasia
- Executive functions included under this heading include awareness,
reasoning, judgment, intuition, and memory
Sensory Integrity and Integration
- Sensory information is a critical component of motor function.
- provides the necessary feedback for determination of initial
position before a movement, error detection during the movement,
and movement outcomes necessary to shape further learning
closed-loop system of motor control is defined as “a control
system employ- ing feedback, a reference of correctness,
computation of error, and subsequent correction in order to
maintain a desired state.”
variety of feedback sources are used to monitor movement
including: visual, vestibular, proprioceptive, and tactile inputs.
somatosensation (or somatosensory inputs) is
sometimes used to refer to sensory information received from the
skin and musculoskeletal systems.
- CNS analyzes all available movement information, determines
error, and institutes appropriate corrective actions as necessary.
- The primary role of closed-loop systems in motor control appears
to be the monitoring of constant states such as posture and
balance, and the control of slow movements, or those requiring a
high degree of precision or accuracy
pen-loop system of motor control is a “control system with
preprogrammed instructions to a set of an effectors; it does not
use feedback information and error- detection processes.”
schema that contain “a rule, concept, or relationship formed on
the basis of experience.”
Joint Integrity, Postural Alignment, and Mobility
- Joint range of motion (ROM) and soft tissue flexibility are
important elements of motor function
- limitations restrict the normal coordinated action of muscles and
alter the biomechanical alignment of body segments and posture.
ELEMENTS OF THE M'R FUNCTION EXAMIN$ION
Includes : tone, reflex integrity, cranial nerve integrity, muscle
performance, taxonomy of task, videography
Tone
- is defined as the resistance of muscle to passive elongation or
stretch
- It represents a state of slight residual contraction in normally
innervated, resting muscle, or steady-state contraction.
Tone is influenced by a number of factors, including:
(1) physical inertia
(2) intrinsic mechanical-elastic stiffness of muscle and connective
tissues
(3) spinal reflex muscle contraction (tonic stretch reflexes).
postural tone is preferred by some clinicians to describe a
pattern of muscular tension that exists throughout the body and
affects groups of muscle
Tonal abnormalities are categorized :
(1) hypertonia (increased above normal resting levels)
(2) hypotonia (decreased below normal resting levels)
(3) dystonia (impaired or disordered tonicity).
Hypertonia
- Spasticity is a motor disorder characterized by a velocity
dependent increase in muscle tone with increased resistance to
stretch; the larger and quicker the stretch, the stronger the
resistance of the spastic muscle
Chronic spasticity is associated with contracture, abnormal posturing
and deformity, functional limitations, and disability.
Spasticity arises from injury to descending motor pathways from the
cortex (pyramidal tracts) or brain- stem (medial and lateral
vestibulospinal tracts, dorsal reticulospinal tract) producing disinhibition
of spinal reflexes with hyperactive tonic stretch reflexes or a failure
of reciprocal inhibition
- hyper excitability of alpha motor neuron, occurs as part of upper
motor neuron (UMN) syndrome
Rigidity
- is a hypertonic state characterized by constant resistance
throughout ROM that is independent of the velocity of movement
(lead-pipe rigidity
- It is associated with lesions of the basal ganglia system
(extrapyramidal syndromes) and is seen in Parkinson’s disease
- Cogwheel rigidity refers to a hypertonic state with superimposed
ratchet-like jerkiness and is commonly seen in upper extremity
movements
Decorticate and Decerebrate Rigidity
- Severe brain injury can result in coma with decorticate or
decerebrate rigidity.
Decorticate rigidity refers to sustained contraction and
posturing of the upper limbs in flexion and the lower limbs in
extension.
- Decorticate rigidity is indicative of a corticospinal tract lesion at the
level of diencephalon (above the superior colliculus)
Decerebrate rigidity (abnormal extensor response) refers to
sustained contraction and posturing of the trunk and limbs in a
position of full extension
- indicates a corticospinal lesion in the brainstem between the
superior colliculus and vestibular nucleus.
Opisthotonus is characterized by strong and sustained
contraction of the extensor muscles of the neck and trunk,
resulting in a rigid, hyperextended posture.
Dystonia
- is a prolonged involuntary movement disorder characterized
by twisting or writhing repetitive move- ments and increased
muscular tone.
Dystonic posturing refers to sustained abnormal postures
caused by co- contraction of muscles that may last for several
minutes, for hours, or permanently (3) problems with psychometric properties (unequal distances of
scores).
Hypotonia

Hypotonia and flaccidity are the terms used to define decreased or

absent muscular tone.

- Lower motor neuron (LMN) syndrome results from

lesions that affect the anterior horn cell and peripheral nerve

- Acute UMN lesions (e.g., hemiplegia, tetraplegia, paraplegia) can

produce temporary hypotonia, termed spinal shock or cerebral
shock depending on the location of the lesion.

Examination of Tone

An examination of tone consists of

(1) initial observation of resting posture and palpation

(2) passive motion testing

Special Tests
(3) active motion testing
- In the lower limbs, spasticity can be examined using the pendulum
- A subjective determination of the degree of tone can be made. test.
Therapists need to be familiar with the wide range of normal and
abnormal tonal responses to develop an appropriate frame of
myotonometer is a handheld computerized electronic device
reference to grade tone.
developed by Leonard and co-workers that can be used to
measure muscle tone.
For documentation in the medical record, tone is typically graded on
a 0 to 4+ scale:
Documentation

0 No response (flaccidity)
 - Documentation of tone abnormalities should include a

1+ Decreased response (hypotonia)
 determination of the specific body segments demonstrating
2+ Normal response
 abnormal tone, the type of abnormality present, whether the
3+ Exaggerated response (mild to moderate changes are symmetrical or asymmetrical, resting postures and
associated signs, and factors that modify (increase or diminish) tone.
hypertonia)
4+ Sustained response (severe hypertonia) Reflex Integrity

Deep Tendon Reflexes

Modified Ashworth Scale
A reflex is an involuntary, predictable, and specific response to a
- The Modified Ashworth Scale (MAS) is a clinical scale used to
stimulus dependent on an intact reflex arc (sensory receptor,
assess muscle spasticity that is in commonly used in many
afferent neurons, efferent neurons, and responding muscles or
rehabilitation facilities and spasticity clinics
gland).

Limitations with use of the scale include

- deep tendon reflex (DTR) results from stimulation of the stretch-
sensitive IA afferents of the neuromuscular spindle producing
(1) inability to detect small changes muscle contraction via a monosynaptic pathway.

(2) inability to distinguish between soft tissue viscoelastic and neural The quality and magnitude of responses should be carefully
changes, documented. In the medical record, reflexes are graded on a 0 to
4+ scale:
0 Absent, no response
 in adult patients following brain injury are always indicative of
1+ Slight reflex, present but depressed, low normal neurological involvement.
2+ Normal, typical reflex

Flexor withdrawal reflex is generally the simplest to observe
3+ Brisk reflex, possibly but not necessarily abnormal
and is judged by appearance of an overt movement response.
4+ Very brisk reflex, abnormal, clonus

Tonic neck reflexes, on the other hand, bias the musculature

and may not be visible through overt movement responses

jendrassik maneuver, the patient hooks together the fingers

of the hands and strongly pulls them apart

Reflex spread (the extension of the response beyond the

muscle normally expected to contract) is indicative of UMN
syndrome.

Superficial Cutaneous Reflexes

- are elicited with a light stroke applied to the skin.

plantar reflex (S1, S2) is tested by applying a stroking stimulus

on the sole of the foot along the lateral border and up across the
ball of the foot.
Documentation of Reflex Integrity

Chaddock’s reflex (or sign) is elicited by stroking around Documentation of reflex abnormalities should include a
the lateral ankle and up the lateral dorsal aspect of the foot. determination of:

abdominal reflex is elicited with brisk, light strokes over the (1) specific reflexes tested
skin of the abdominal muscles.
(2) the degree of abnormality observed
Primitive and Tonic Reflexes
(3) associated signs (e.g., UMN syndrome)
- Primitive and tonic reflexes are present during infancy as a stage
in normal development and become integrated by the CNS at an (4) factors that modify reflexes
early age.

Persistent reflexes (sometimes termed obligatory

reflexes) beyond the expected age of development or appearing
Cranial Nerve Integrity

Neurogenic atrophy accompanies LMN injury (e.g., peripheral
nerve injury, spinal root injury) and occurs rapidly, generally within 2
to 3 weeks.
Examination of Muscle Bulk
- During the examination, the therapist should visually inspect the
muscle symmetry and shapes, comparing and contrasting their size
and contour.
Strength and Power
- Muscle performance is “the capacity of a muscle or a
group of muscles to generate forces.
- Muscle strength is “the muscle force exerted by a muscle or
a group of muscles to overcome a resistance under a specific set
of circumstances.”
- Muscle power is “work produced per unit of time or the
product of strength and speed.”
Of equal importance are the integrated actions of the CNS
(neuromuscular control factors) acting on motor units, including:
(1) the number of motor units recruited
(2) the type of motor units recruited
(3) the discharge rate and continuing modulation of motor units
Examination of Muscle Strength and Power
Estimates of strength can be made based on observations during
active functional movements using the following criteria:
• Muscles with visible movement that are unable to
overcome gravity and move throughout the ROM
receive a poor grade. 

• Muscles that are able to move against gravity throughout
the range but can take no additional resistance receive a
fair grade. 

• Muscles that can move against gravity throughout the
range and against some resistance (moderate resistance)
receive a good grade. 

• Muscles that can move throughout the range and against
strong resistance receive a grade of normal. 

Patients with stroke typically demonstrate a variety of deficits when
tested with an isokinetic dynamometer, including:
(1) decreased torque overall in the more affected limb when
compared to the less affected limb
(2) decreased torque with increasing movement speeds
(3) decreased limb excursion
(4) extended times to peak torque development and the duration
time peak torque is held
(5) increased time intervals between reciprocal contractions.
Documentation of Strength and Power
- Documentation of strength and power changes should include a
determination of the specific muscles and body segments tested
and tests used
Muscle Endurance
- Muscle endurance is “the ability to sustain forces repeat- edly or to
generate forces over a period of time.”
- An examination of muscle endurance is important in determining
functional capacity
Fatigue is an overwhelming sustained sense of exhaustion and
decreased capacity for physical and mental work at the usual level.
Exhaustion is defined as the limit of endurance, beyond which no
further performance is possible.
overwork weakness (injury), defined as “a prolonged
decrease in absolute strength and en- durance due to excessive
activity of partially denervated muscle.”
Delayed onset muscle sore- ness (DOMS) is prolonged
in patients with overwork weakness, peaking between 1 and 5 days
after activity.
Examination of Fatigue
- An examination of fatigue begins with the initial inter- view.
- It is important to identify the fatigue threshold, defined as “that
level of exercise that cannot be sustained indefinitely
- Self-assessment questionnaires are particularly useful for the
patient with significant fatigue.
Documentation
Documentation of muscle endurance should include a determination
of:
(1) activities that result in debilitating fatigue, including onset, duration,
and recovery
(2) level of assistance or assistive devices required
(3) frequency and effectiveness of rest attempts
(4) compensatory strategies adopted and effectiveness
(5) impact on quality of life. Results of specific questionnaires and
tests are documented.
Voluntary Movement Paerns
Synergies are functionally linked muscles that are constrained by
the CNS to act cooperatively to produce an intended motor action.
- They are used to simplify control, reduce or constrain the degrees
of freedom, and initiate coordinated patterns of movement
Degrees of freedom refers to the number of separate
independent dimensions of movement that must be controlled by
engaging these cooperative units of muscle action.
The CNS controls patterns of:
(1) single limb and multiple limb movements
(2) bilateral (bimanual) symmetrical and asymmetrical movements
(3) reciprocal movements
(4) patterns of proximal stabilization and postural support.
- Movements are also appropriately timed with events in the
environment (coincident timing).
Abnormal Synergistic Patterns
- Synergistic organization of movement may be disturbed with
pathology of the CNS.
obligatory synergies, defined as movements that are
primitive and highly stereotyped.
Examination
- The examination of abnormal synergies is both qualitative and
quantitative.
Fugl-Meyer Post-Stroke Assessment of Physical
Performance provides an objective and quantifiable measure of
obligatory synergistic dominance and recovery after stroke
Documentation
Documentation of abnormal synergies should include a
determination of:
(1) what abnormal synergies are present
(2) the overall strength of the synergies present
(3) the strongest components in each synergy
(4) the influence of other UMN signs on synergies
(5) what variations in movement from the typical synergies are
possible
(6) the effect of obligatory synergies on function (basic activities of
daily living [BADL], functional mobility skills).
Activity-based Task Analysis
- Examination at the functional level focuses on observation
and classification of functional abilities and the identification
of activity limitations.
Activity-based task analysis is the process of break- ing a
specific activity down into its component parts to understand and
evaluate the demands of the task and the performance
demonstrated
activity demands refers to the requirements imbedded in
each step of the activity
environmental demands (constraints) refers to the physical
characteristics of the environment or features required for
successful performance of movement (regulatory conditions).

Taxonomy of Tasks
- Tasks are commonly grouped into functional categories.
Activities of daily living (ADL) refer to those daily liv- ing
skills necessary for an adult to manage life
Basic ADL (BADL) include grooming skills (oral hygiene,
showering or bathing, dressing), toilet hygiene, feeding, and personal
device care.
Instrumental ADL (IADL) include money management,
functional communication and socialization, functional and community
mobility, and health maintenance.
Functional mobility skills (FMS) refer to those skills
involved in:
 1. Bed mobility: rolling, bridging, scooting in bed, moving Stages of Motor Learning
from supine-to-sit and sit-to-supine
cognitive stage the learner develops an understanding of task.
2. Sitting: scooting
- During practice cognitive mapping allows the learner to assess
abilities and task demands, identify relevant and important stimuli,
3. Transfers: moving from sit-to-stand and stand-to-sit, 

and develop an initial movement strategy (motor program) based
transfers from one surface to another (e.g., bed-to-
on explicit memory of prior movement experiences
wheelchair and back, on and off a toilet, to and from a
car seat), and moving from floor-to-standing
associated stage of motor learning.

4. Standing: stepping - During this stage, the learner practices and refines the motor
patterns, making subtle adjustments.
5. Walking and stair climbing
- Spatial and temporal organization increases while errors and
- Tasks can also be grouped according to the actions and type and extraneous movements decrease.
nature of motor control (neuromotor processes) required during
performance of the task. These include: - Performance becomes more consistent and cognitive activity
decreases.
(1) transitional mobility
autonomous phase of motor learning.
(2) stability (static postural control)
- The learner continues to practice and refine motor patterns. The
(3) dynamic postural control (controlled mobility) spatial and temporal components of movement become highly
organized
(4) skill.
- Performance is at a very high level
During functional task analysis, key elements the therapist should
observe and document include:

(1) the ability to organize and control movements

(2) economy of effort

(3) the success of attaining an action-goal (out- come)

(4) ability to easily and successfully adapt a task

(5) ability to easily and successfully adapt to changing environments

(6) verbal cues and assistance, if any, required.

Videography

- The qualitative analysis of motor skills can be enhanced by the use

of videography.

- Recordings made at 3 or 6 weeks of recovery can be compared

easily without reliance on the therapist’s memory or written notes.

M'R LEARNING

Motor learning is a complex process that requires spatial, temporal,

and hierarchical organization within the CNS that allows for
acquisition and modification of movement.