Week 1: CNS/central structures/motor tracts

CNS Development:
● Begins in utero
● Continues in childhood and adolescence for many structures
● Some areas (the frontal lobe) develop until age 25
● Learning, experiences, SES also affect development

Areas of the brain:

1. Cortical / subcortical
2. Central / peripheral
3. Supraspinal / spinal
4. Callosal / subcallosal

Central Structures:
● Frontal lobe
○ Thinking, planning, problem solving, emotions, behavioral control, decision making
● Prefrontal Association Area
○ Action identification and evaluation
○ Reward proximity, reward delivery
○ Errors, surprise, effort
● Motor Cortex [[ M1 ]] (the one that starts the movement & grades for force)
○ Contains the motor homunculus - represents multiple muscles and movements for activation.
Also present through PMA, SMA
○ Role of M1: for the CONTRALATERAL side (opposite side of the body); movement initiation,
amount of force, rate of change of force.
○ Origin for 40% of corticospinal tract fibers (distal movement in the arms (wrist, hand and finger
movement))
○ Damage: no initiation of movement - paralysis or paresis on opposite side, out of control force.
● Supplementary Motor Area [[ SMA ]]]
○ Representations of proximal and distal muscles and movements
○ Primary function: planning for complex, sequential movements and bilateral movement
○ Secondary function: execution (body orientation upright) - direct route & gross grasp and release
- indirect through M1
○ Activated by internal cues (motor imagery)
○ Damage: loss of bilateral coordination/movement and sequential movements.
● Premotor area [[ PMA ]]
○ Representations primarily of proximal muscles and movements.
○ Orienting body and arm toward a target.
○ Activated by external cues
○ Damage: ex: asking someone to reach for something and it doesn’t make sense to them
● Parietal Cortex
○ Sensory perception and basic interpretation and special aspects of sensation
○ Damage: problems interpreting sensory information
● Temporal Lobe
○ Memory, understanding language, facial recognition, speech, hearing, vision, emotions
● Occipital Lobe
○ Vision, basic visual processing, color identification
● Cerebellum
○ Coordination and planning of movements
○ Monitors ongoing execution of movement and error correction
○ Posture and equilibrium
● Thalamus [[ second relay station ]]
○ Secondary processing for all somatic sensation except smell
 ● Basal Ganglia (Striatum)
○ Nuclei: caudate, putamen, globus pallidus, substantia nigra, subthalamic
○ Pathways: direct/excitatory & indirect/inhibitory
○ ^ damage results in Huntington’s disease(direct) and Parkinson’s disease(indirect)
○ Function is movement, proprioception, muscle tone and force, aids in motor learning
● Corpus Callosum
○ Provides all communication between R and L hemispheres
○ This is why working the unaffected limb during rehabilitation can actually improve function of the
affected limb.
● Brainstem
○ Oldest part of brain
○ Center for breathing, blood pressure and heart rate
○ Cranial nerves - swallowing and eye movement

Motor Tracts originate from Motor Cortex

- Corticospinal tract: pyramidal tract

● Anterior: (uncrossed) bilateral axial and shoulder girdle mm
● Lateral: (crossed at level of medulla) contralateral movement of limbs: UE and LE
● Responsible for fractionation of distal UE musculature
● 40% originate in primary motor cortex and not mature until age 10
● Damage: problems with moving fingers independently (individuated movements)
- Corticobulbar Tract: extrapyramidal
● Swallowing
● Medical term for difficulty swallowing = dysphagia
- Vestibulospinal Tract: Extrapyramidal
● Medial: positioning of head and neck
● Lateral: Balance
- Rubrospinal Tract: extrapyramidal tract
● Contralateral limb movement
● Control of muscle tone in flexor muscles
● Damage leads to LMN impairment
- Pontine Reticulospinal tract: Extrapyramidal
● Automatic posture and gait-related movements
● Controls axial and LE movement for posture and gait
● Medial: LE extensors motor neurons; lateral: flexor motor neurons
● Damage: abnormal stepping pattern
- Olivospinal Tract: unconscious proprioception (knowledge of where your joints are in space), involved in
balance.

➔ Complete spinal cord injury (SPI) (ASIA A): no motor or sensory function left below the injury

Spinal Cord to Periphery

● Leaves spinal cord through anterior horn cells
● Motor unit in the muscle (final common pathway)

Cortical-striatal loops: (each loops back to where it started)

1. MOTOR LOOP
Cortical areas: M1/SMA/PMA→ Basal Ganglia (Putamen) → Thalamus →
2. EYE MOVEMENT LOOP
Parietal/Prefrontal Cortex → Basal Ganglia (Caudate) → Thalamus →
3. PREFRONTAL LOOP
Dorsolateral Prefrontal Cortex → Basal Ganglia (Anterior Caudate) → Thalamus →
 4. LIMBIC SYSTEM: ORBITOFRONTAL LOOP
Orbitofrontal cortex → Basal Ganglia (Caudate) → Thalamus →
5. LIMBIC SYSTEM: CINGULATE LOOP
Anterior Cingulate Cortex → Basal Ganglia (Ventral portion) → Thalamus →

UMN Lesions: LMN Lesions:

- weakness - weakness
- No atrophy - atrophy (thinning of muscle)
- Increased reflexes - decreased reflexes
- Increased muscle tone - decreased muscle tone
- Spasticity

Movement is constrained by three factors:

1. Person - action/movement, perception, cognition
2. Task
3. Environment

1. Movement is constrained by the person

- Action
● Nervous system control of the body for movement
- Perception
● Peripheral sensory input and higher-level processing
- Cognition
● Attention, motivation, planning, problem-solving
● Emotion (e.g., anxiety, depression)

2. Movement is constrained by the task

- Classification by function
- Classification by critical attributes that regulate neural processes
● Discrete (has start and stopping point) and continuous movement
● Stable or mobile base of support (BOS)
● Presence or absence of manipulation component
● Movement variability: open or closed
- Allows development of taxonomy (progression) of tasks from simplest to most complex

3. Movement is constrained by the environment and its requirements

- Environmental expectations / forces / speed needed

Week 2: Motor Control Theories

● No one theory is sufficient to explain motor behavior

1. Reflex Theory
- Sensation in = there will be movement out
- Helps us interpret behavior: explains some observed movement
- Guides therapeutic techniques: icing, stretch reflex, tapping, joint approximation
2. Hierarchical Theory
- Top-down organization of the brain: motor cortex provides instruction to the midbrain, then to
the brainstem and spinal cord.
- Incoming sensation drives voluntary motor response
- 3 really strong theory bases that are used today as far as techniques go (don’t need to know
them)
- Assumptions of recovery: damage leads to release of abnormal low-level reflexes.
- Recovery of functions occurs once higher centers exert control again over lower centers
 - Functional skills will return once abnormal movements are inhibited
3. Systems Theory
- The person’s entire motor system must be considered in relation to the task being performed
throughout movement
- Motor redundancy in the brain
- Degrees of freedom problem
- Hierarchical control helps simplify control of the body’s multiple degrees of freedom. Higher level
activation is common but not exclusive.
- Synergies can be normal or abnormal
4. Dynamic Systems Theory
- Movement develops by itself from chaos
- Principle: when a system of individual parts comes together, its elements behave collectively in
an ordered way.
- Nonlinear behavior= one that transforms into a new configuration when a single parameter is
gradually altered to a critical value. Example: walking transitioning to running
- Highly stable behaviors are viewed as an attractor state
- Stable movement patterns become more variable just before transition to a new movement
pattern

Vocab to know:
● Constraint: limitation / restriction
● Agonist: muscle that works
● Antagonist: muscle opposite / restricts movement
● Synergy: group of muscle that work together

➔ Stretch Reflex and Reciprocal Inhibition - via muscle spindle

● Checking for spasticity: high, moderate, and mild
1. Initial free period - initial movement
2. Sudden Catch
3. Slow relaxation

➔ Autogenic Inhibition: relaxation in the same muscle that is experiencing muscle tension via the golgi
tendon organ
- Will occur if a stretch is maintained for more than 6 seconds or if they muscle contracts forcefully
- Examples: static stretch and PNF stretch

Degrees of freedom in the shoulder: 4 degrees

1. ext/flex
2. abd/add
3. inter/external rotation
4. Horizontal abd/add

● Example Questions:
1. Neurodevelopmental Treatment (NDT or the Bobath method, 1960’s) assumes that sensation can be used to
drive appropriate movement and improve cortical control over lower centers. This treatment derives from
a. Reflex theory
b. Hierarchical theory
c. Systems theory
d. Dynamic systems theory
2. Brunnstrom therapy (1950’s), relies on the use of repetitive sensation to elicit (bring forth) movement. Recovery
does not occur until lower centers are fully developed, then higher control centers can be developed. This therapy
relies on
a. Reflex theory
 b. Hierarchical theory
c. Systems theory
d. Dynamic systems theory

3. Systems theory and dynamic systems theory suggest that movement occurs in response to
a. Personal movement characteristics
b. Task characteristics
c. Environment characteristics
d. a and b.
e. a, b, and c

4. Dynamic systems theory can fully explain motor behavior today.

a. True
b. False

Neuroscience of Emotion:
● Affective Neuroscience
- Emotional experience (Brain)
- Emotional expression (action)
● Limbic System: Papez Circuit
- Collection of cortical areas that form a ring around the brainstem and corpus callosum that are
closely associated with emotion and emotional expression
- Includes olfactory bulbs (smell)
- Temporal Lobe → Hippocampus → mammillary body → anterior thalamus → cingulate gyrus
(emotion formation and processing [experience]) → hippocampus → hypothalamus (emotional
expression)
- Deficit in the papez circuit = can lead to lability: spontaneous laughing or crying without an
identifiable cause
● Temporal Lobe
- Auditory, olfactory, visual, vestibular sensory processing
- Perception of spoken and written language
- Damage: kluver-bucy syndrome: increased sexual activity, hyperorality, lack of fear, poor memory
● Hippocampus
- Curves around basal ganglia
- Long term memory
- Damage = amnesia
- Parahippocampus: spatial memory
- Mammillary body: memory
● Anterior Thalamus
- Relay station for all sensory information except smell.
- Pain
- Motor control, sleep, wakefulness
● Cingulate Gyrus (cortex)
- Emotion formation and processing (experience)
- learning/ cognition, memory, reward recognition
- If damaged: RAGE
● Hypothalamus - emotional expression
- Fight or flight
● Amygdala
- Feeding, fighting, mating, maternal care
- Anxiety, aggression and learned fear
- Emotion and social cognition
● Nucleus Accumbens
 - Addiction and motivation

Neuroanatomy of Anxiety:
Anxiety: anticipation of potential harm in the future
- Fear: triggered by a real and imminent threat
● Salience is one of the most important factors in choosing an OT intervention activity [[connection to what
is happening]]
● Hyperactivation of the amygdala and insula is common to PTSD, SAD, and phobias
● Amygdala may drive the inappropriate threat determination and emotional dysregulation seen with
anxiety

Week 3: Motor Learning

Motor Learning: The study of the acquisition and/or modification of movement.
- A set of processes associated with practice or experience leading to relatively permanent changes in the
capability for movement. (means it is never permanent) - the more you have done an activity, the more
you learn it. Example: riding a bike.
● Motor learning studies have traditionally been related to healthy “normal” children and adults. Therefore,
translation to people with injuries may or may not be feasible - use thoughtfully.
Recovery of function: is the term used for reacquisition or modification of movement skills lost due to injury.
(example: having a stroke and not being able to move your arm - recovery of function would be relearning to move
your arm again - modification if it moves in a different way BUT goal of movement is achieved)

Types of knowledge:
1. Declarative knowledge
- Knowledge that can be consciously recalled
2. Procedural knowledge
- A set of processes associated with practice or experience leading to relatively permanent changes
in the capability for producing skilled action
● Performed without attention or conscious thought
● Develops slowly through tons of repetition over many trials
● Motor memories may be stored in association cortices

● Motor Learning can only be measured indirectly

1. Time: decreased reaction time (RT) and movement time (MT)
- Reaction time: time of tone (start) to the start of the movement
- Movement time: start of movement to peak of movement
2. Error: decreased end point error
3. Velocity: increased speed
4. Variability: decreased movement variability.
- Improved temporal and spatial coordination (time and space) of joint movement
- Decreased joint stiffness (moving more freely)
5. Movement characteristics: changes in movement kinematics (trajectory, velocity, acceleration)
- Improved muscle activation patterns
Early changes during motor learning happen in the cerebellum

Changes in M1 during motor learning: during learning, M1 is picking up a lot of information/ working
We don’t want to disrupt while it is learning new skills
Disruption: may prevent skill consolidation - too much information at once, too much talking, too much variability

Activity- Related Changes in neurons: more branching dendrites = more synapses = long term enhancement

Theories related to stages of motor learning:

***Fitts & Posner three-stage model***study of modification of movement / recovery of function
 ● Acquisition Stage: Initial learning of the motor skill
- High cognitive demand - have to think hard about it
- Performance variable
- Improvements large
● Associative Stage: Skill refinement- have a general idea of what skill is
- Improvements occur more slowly
- Less cognitively intense, more motor practice
- Lasts days-weeks depending on intensity of practice
● Autonomous Stage: Automatic skill ** This is the goal stage. They have learned the movement and can
practice it without any trouble as long as they don’t bring it back to conscious thought.
- Low degree of attention required

Practical applications of motor learning:

Motor Learning Principles:
1. Motivation is required for the person learning the movement. CRITICAL
- Has to be followed by success
2. Problem solving required with practice
- Body will go back to a simpler, more familiar routine. [ just right challenge ]
3. With difficult or unfamiliar tasks, safer, or more familiar patterns will be used
4. Motor learning involved many areas of CNS

Task Features:
1. Closed task: key task feature stationary object
- Performance must fit spatial requirements of environment
- Timing is self paced
Example: spoon sitting on a table, dressing
2. Open task: supporting surfaces, objects or other people are in motion from one trial to the next.
- Performance must fit both spatial and temporal requirements of the environment
- Timing and/or changes required are unpredictable
( examples: treadmills, boats, moving sidewalks, moving people around you)

Feedback:
1. intrinsic feedback: feedback from sensation (vision, somatosensation)
2. extrinsic feedback: external and additional feedback. (verbal, metronome)
3. Knowledge of performance: feedback related to movement patterns
4. Knowledge of results [KR] : terminal feedback about movement outcome (usually done after a number of
trials)
- Give results without any other movements (as soon as movement is completed)
- fading/ decreasing feedback appears to be better than constant feedback
- Summary of KR is best after 15 trials for simple tasks, after 5 trials for complex tasks
- Best with adults
session
Massed vs distributed practice
1. Massed practice: practice is blocked into one set time
- Rest time is less than practice time per session
(ex: doing movement for 2 min, rest for 30 seconds)
- Precaution: fatigue and potential injury
2. Distributed practice: practice time is distributed over a longer time period
- Ex: 3 times per week

Constant vs. variable practice:

 1. Variable task practice: tasks changes; conditions of tasks performance change
- Increases the ability to adapt and generalize learning
2. Constant task practice: tasks with minimal variation
- Tasks always performed under constant conditions

Random vs. blocked

1. Random practice (eg, 5 tasks in random order) results in contextual interference
- Aids generalization
- Slows initial acquisition; aids long term retention
- Most effective with skills using different motor patterns
- Personal characteristics may influence effectiveness
● Random practice limitations
- Inappropriate until task characteristics understood by learner
- Not shown effective for teens with Down’s syndrome
2. Blocked practice: Tasks always performed in same order

Whole vs. part training

1. Part Training: When tasks can be analyzed into subcomponents
- Part-Whole: Part-task training followed by whole application
2. Whole training:
- appropriate when task must be completed as a full sequence; ie, no subcomponents can be
clinically identified
Part/Whole training: example could be transferring: tasks before whole transfer (locking wheel chair, etc) is
completed

Antecedent events vs. consequences

1. Antecedent events = event(s) or actions occurring before a behavior that triggers it. (drives our
movement)
- Natural or artificial environment
- Cuing
- Prompting
2. Consequence = events or actions, planned or unplanned, that follow a sequence
- Praise
- Knowledge of results

Neuroplasticity
● Neural Plasticity: Lifelong short-term and long-term neural modifiability due to changes in sensory input
● Plasticity: any relatively enduring change in cortical properties, either structural or functional, in response
to altered input or output
- Short Term : efficiency or strength of synaptic connections
- Long Term : structural changes in neurons themselves
- Organization and number of connections
History:
1997: New neural growth feasible - stem cells from human adult brain were shown to proliferate and differentiate
into neurons and glia.

Recovery of function terms used by OTs:

1. spontaneous recovery: initial or early recovery that occurs in the absence of therapy
2. activity -induced recovery of function: improvements related to training

Recovery of Function:
1. Restorative: direct change within the nervous system.
- All nerves in motor cortex reconnected & exact movement has returned
 - Recovery of damaged neural tissue by nearby neurons that take over exact function of damaged
ones
2. Compensatory: indirect change within nervous system
- Changes in cortical representation. Can be functional or dysfunctional recovery of function
(phantom pain = dysfunctional)
- Completely different neural circuits enable function

Responses to injury:
Destruction of neurons at the exact site of the lesion or insult
● Diaschisis – temporary disruption of function produced by the shock of damage in brain tissue, leading in
loss of input from a nearby injured area of the brain.
- Resolves in 3-6 months
- Theory: early recovery of function may be due to resolution of diaschisis.
● Edema – creates pressure (swelling)
- Local to the lesion or remote from it
- Resolution occurs naturally, or following surgery or shunt
- Resolution may improve function

Intercellular level neural recovery:

● Denervation supersensitivity: an intracellular response in which the postsynaptic membrane becomes
hypersensitive to a released neurotransmitter (restorative) Example: PD (when 90% of nerve fibers in
substantia nigra are gone, remaining fibers become super sensitive to dopamine)
● Silent synapses: unmasking of previously silent synapses. Increased dendritic branching / spine density
(compensatory)

Neural regeneration and collateral sprouting:

1. Neural regeneration: sprouting of injured synapses (long term response)
2. Collateral sprouting: short term response.

Reorganization following lesions:

- Use of ipsilateral motor pathways - 90% cross over from cortical cortex
- Cross-modality plasticity (bach-y-rita)
- Example of blind man seeing using his tongue
- Brain can be retrained to substitute one sense for another
- Rerouting / relearning of senses
- May not be possible if large areas are damaged.
- Assistance from SMA, PMA
- Recovery function: compensatory

Human studies using TMS: if an area of the brain is destroyed by CNS damage, no intervention can recover lost
function from that specific area.
- After stroke, the excitability of the motor cortex is reduced and cortical representation of affected muscle
is decreased.

***To improve neuroplasticity: basic principles of experience - dependent plasticity?

1. Repetition
- Use it or lose it - brain “shuts off area” when it is not used.
- Use it and improve it - motor learning: just right challenge to use and improve skill
2. Specificity - very specific about what movement you want to accomplish.
3. Intensity - focused intensity
4. Time - development of neuroplasticity
5. Salience - importance
 6. Age - the younger the better, the older the more difficult for neuroplasticity however it is still present
7. Transference - transfer of one side of the brain to the other.
8. interference - internal/external environment issues that cause problems with development of skill

Principles of neurorehabilitation:
● Use real and common objects - not something that is made up and is common to the person you are
working with.
○ The object drives temporal sequencing ( timing ) of muscle activation, hand shaping (shapes the
grasp), and development of force.
○ The object is going to drive how we approach with our grasp (shape of hand, motion of wrist and
arm)

BEHAVIORS ASSOCIATED WITH SPASTICITY

- Hyperactive stretch reflexes

- Abnormal posturing of the limbs
- Excessive coactivation of antagonist muscles
- Associated movements
- Clonus
- Stereotyped movement synergies

Week 4 neural recovery/ muscle physiology/ cortical neuroplasticity

Muscle physiology cortical neuroplasticity:

[[ entire muscle -> group of fascicles -> muscle fiber inside -> myofibril]]

Strength (force): ability to generate sufficient muscle tension for posture and movement

● ***Force depends on
- Number and type of motor units recruited
- Rate of discharge frequency in cortex ***
● Motor unit: the motor neuron (dendrites and axon) and the muscle fibers it innervates

Types of motor units

- Type FF: fast-twitch, fatigable

- Type FR: fast-twitch, fatigue-resistant
- Type S: slow-twitch, highly fatigue-resistant

Every muscle has all 3 types of motor units. (However, the percentage of each type differs)

- For example, eyelid muscle has primarily FR mu

- For example, back muscles have primarily S mu
- But even with these, each muscle has all 3 types of motor units

Skeletal muscle changes with aging:

- Number of muscle fibers decrease

- Number of motor units decrease

DENERVATION AND REINNERVATION:

when motor units die and neighboring motor units take over.
(aging examples with neurons)
Fast muscle fiber becomes a slow one….

Recruitment and Derecruitment: Henneman size principle

- Allows us to control force so movements aren’t jerky but energy efficient

Motor System Impairments:

● Primary Neuromuscular Impairments

- Problems that represent a major constraint on functional movement

● 1. Muscle weakness

There is a need to examine weakness in the patient with CNS pathology

Growing research supports that paresis is as important as spasticity
Problem: decreased recruitment of paretic muscles

The capacity to generate force in an isolated muscle does not predict the ability of that muscle to
work in concert with others in a task-specific way. (just because someone does biceps curls with a
weight doesn’t mean they will be able to bring a spoon to their mouth to eat)

● 2. Abnormalities of muscle tone

Characterized by a muscle resistance to passive stretch

Contributions to tone abnormalities to functions deficits are not well understood

Hypertonicity= (spasticity)
spasticity = velocity dependent increases in resistance to passive stretch
associated behaviors: hyperactive stretch reflexes, abnormal posturing of limbs, clonus

Rigidity = velocity independent

hypotonia = reduction in the stiffness of a muscle to lengthening (commonly in down’s syndrome,

developmental delays, spinocerebellar lesions)

● 3. Coordination problems and involuntary movements

Sequencing, timing and grading of the activation of multiple muscles groups

Person has sufficient strength
Movements are awkward/ uneven / inaccurate

Coordination requirements: appropriate activation and sequencing of mu, appropriate timing.

Grading of the activation of multiple muscle groups

Involuntary movements:

● Dystonia: Sustained abnormal postures

● Chorea: Involuntary jerking, twitching, or writhing motions
● Associated movements
● Tremor: unintentional, somewhat rhythmic, muscle movement involving to-and-fro
movements of one or more parts of the body. 20 types, including essential, resting and
intention.
 ● 4. Activation and Sequencing problems

Abnormal synergies (lack of fractionation)

Problems with coactivation of agonist and antagonist
Impaired interjoint coordination
Altered termination time: rebound phenomenon (involuntary movement when resistance is
suddenly removed)

Scaling forces:

1. Dysmetria
- Traditionally, problems in judging the distance or range of a movement
2. Hypometria
- Underestimation of the required force or range of movement
3. Hypermetria
- Overestimation of the required force or range of movement

Timing Problems:

- Reaction time = time from decision to onset of movement. Affected by physical, psychological, and
cognitive factors
- Movement time = time from onset to execution

Secondary Motor Impairments:

- Spasticity changed the physical properties of muscle and other tissues (passive muscle stiffness, active
muscle stiffness)
- Paresis results in underlying structural changes to muscle (accumulation of CT, loss of sarcomeres, fat
deposits in tendons, loss of muscle mass)

Week 5: Task-Specific training (TST):

Task-specific Training:

● Patients practicing context-specific motor tasks and receive some form of feedback
● Evolved from movement science and motor skill learning literature
● Rehabilitation focus: improve performance in functional tasks through goal-directed practice and
repetition

○ Train function tasks rather than impairment (ex reaching not shoulder strength)

● Synonymous terms: repetitive tasks training (RTT), task-oriented therapy

“Active ingredients”:

- Use of real-world, common objects

- Random order sequence

● different contexts and settings. (overhead reach in kitchen, bedroom, bathroom)

● Different occupational demands and sequences (opening different sized containers)
● Different times of day (eating in the morning, lunch, and evening)

- High # of repetitions
- Massed practice
- Just right challenge
- Positive reinforcement (every 5 reps for complex tasks, every 15 for simple)
 - Progress from part tasks to whole tasks

Random Order Sequence: To maximize generalization.

What does 1 rep look like?

- Highly variable and task-dependent

- 1 rep = reach + grasp + move/transfer + release
- Some tasks are easier to quantify reps (sorting silverware vs. brushing teeth)

Week 6: Sensation and Pain

Terminology:
Glabrous- non hairy/ smooth skin.
Mechanoreceptors- set of touch receptors
Nociceptive - pain

Somatosensory Modalities

1. Touch: Mechanoreceptors
2. Proprioception: mechanical displacement of muscles and joints providing position in space

● Static: Proprioception
● Dynamic: Kinesthesia (moving)
● Sensor: Muscle Spindle, Golgi Tendon Organ

3. Thermal: warm and cool stimuli

4. Pain: nociceptive (tissue-damaging) stimuli

● Mechanical
● Thermal
● Polymodal

Cutaneous receptors = touch = mechanoreceptors

Touch: Merkel’s disks (fine touch discrimination)

- Fine discriminative touch - help you feel textures easily.

- Identifies edges, form, and texture
- Shallow - from surface of skin
- Many in skin of lips and fingertips
- Hairy and glabrous (non hairy) skin

Touch: Meissner’s Corpuscle (think grip)

- shallow
- Fine control of grip
- Help recognize microslips
- Low frequency stretch

Touch: Pacinian Corpuscle (think vibration)

- Extreme sensitivity to vibration but not localization (can’t tell you where in the finger it is happening)

Touch: Ruffini endings (sensitive to stretch)

- Horizontal skin stretch (poor spatial resolution)

 - Lower density in hand than other mechanoreceptors
- Hairy and glabrous skin

Proprioception:

Sensory Basis of proprioception:

● Muscle spindles are present in muscle

○ They signal muscle stretch

● Golgi tendon organs: in ligaments that attach muscle to bone

○ They Signal perception of force

● Joint and cutaneous receptors:

○ discharge near extremes of flexion and extension

Muscle Spindle Action

● Extrafusal fibers = muscle fibers

○ Innervated by alpha motor neurons

● Muscle spindles: measure length and changes in length of muscle fibers (parallel with muscle fibers)

● Intrafusal fibers = receptors within spindles

○ Innervated by gamma (=fusimotor) motor neurons (gamma motor neurons go to spindle)

○ Gamma motor neurons control the sensitivity of muscle spindle

● ***Whenever there is voluntary movement, there is alpha-gamma coactivation***

Gamma system: the muscle spindle facilitates the agonist and inhibits the antagonist muscle fiber ** reciprocal
inhibition **

Golgi Tendon Organs (GTOs)

● Measure force of muscle contraction

○ Found in muscle tendon junction

○ Only sensory (no motor unit)
○ Inhibits the agonist and allows the antagonist to move (autogenic)

Somatosensory processing in neurodevelopmental disorders article:

● Tactile processing in development of social, communicative, and motor behavior

● NDDs have been linked solely to motor systems dysregulation
● Somatosensory response in utero = as early as 8 weeks
● Use touch, vibration, positioning *** providing opportunities as much as we can
 Thermal

● Thermal receptors: separate locations on skin where thermal stimulation elicits the sensation of warmth
or cold.
● Activated by skin temperature 90-113 degrees F

○ With increased warmth, receptors are discharged more frequently

○ Beyond 113, perceived as heat pain by nociceptors

Therapeutic use of sensation

1. NMES: Neuromuscular Electrical Stimulation - strengthens a weak muscle contraction

● Contraindications ( you can NOT do it) : epilepsy, cardiac pacemakers, area of cancer

2. Deep pressure: maintained pressure of underlying muscle tendon. [[inhibitory]]

3. Weight Bearing: facilitates cocontraction, postural holding. Affects muscle spindles and GTO
(changes in length and sense of force)
4. Mirror Therapy: increased visual attention - activation of mirror neurons.

**vision is our strongest sensory organ **

Pain: “a subjective response to distress that cannot be quantitatively measured”

Responses of pain: psychological, pathological, emotional

Two types of pain awareness:

1. Sharp pain - localized to the affected area

● Medium diameter myelinated A-delta fibers (pain and temperature)

● Sharp, fast, precise, and discriminative
● Provides information related to immediate threat and guides the withdrawal response (reflex
response) (ex: stepping on a tack)

2. Throbbing and diffuse pain

● Small diameter unmyelinated C fibers (free nerve endings)

● Arching, burning, throbbing; slow to start and to end; poorly localized
● Demands sustained attention to limit further injury

3 main types of pain sensors:

1. Mechanical
- Most easily activated by intense pressure (cut, stub, pinch)
2. Thermal
- Respond to temperatures below -42 F or above 113 F
3. Polymodal
- Responsible for the second wave of pain (chronic, keeps coming)

Spinothalamic tract:

- There can be mixing of signals with separate streams of sensation traveling from spinal cord to brain.
Integration of pain & fine touch information….separate streams of sensation traveling to the spinal cord
to brain.
● Spinothalamic tract is correlated with the first wave of pain
Spinomesencephalic tract: synapses in brain stem; to insula, amygdala and anterior cingulate cortex

● Emotional and cognitive responses to pain

● Second wave of pain

Theories for Pain Reduction:

1. Gate Theory: (1965; Melzack and Wall)

- The application of non-painful stimuli closes neural “gates” to painful input then pain will not be felt as
much (“blocking gate”)
2. development of endorphins: natural pain killers that can occur with exercise or laughter - help block pain
perception
3. The placebo effect: giving a fake medication that evokes significant analgesia in about 30% of patients.
Associated with release of endorphins in parts of the emotional pain circuit.

6.1 Sensation Lab:

Somatosensory functions:

1. Pain: see above notes

2. Touch see above notes
3. Proprioception see above notes
4. Kinesthesia - awareness of the position and movement of parts of the body by means of sensory organs in
the muscles and joints
5. Stereognosis - mental perception of depth or 3-dimensionality by senses, usually in reference to the ability
to perceive the form of solid objects by touch

Dermatomes: areas of skin that are connected to a single spinal nerve that send signals for things like pressure,
pain, temperature from your skin to the spinal cord to the brain.

Week 8: Postural Control

● No universal definition of posture and balance. No agreement on the neural mechanisms underlying the
control of the functions. Postural control emerges from the interaction of the person, the task, and the
environment.

Terminology:

COM = point that is at the center of mass of all body parts, weighted average of each body segment

● COG = center of gravity.

BOS = base of support - body area in contract with the supporting surface
(both feet when standing, butt when sitting…)
COP = center of pressure

Postural Control

Postural Stability = balance (ability to control the COM within the BOS)

Postural orientation: ability to maintain appropriate relationships between body parts and between body
and environment for a task. ( Gravity, somatosensory systems, visions )

Maintaining balance
 ● ***COM is the key variable to be controlled by the nervous system for postural control***
● When you are balanced, the COM is maintained over BOS

Options for loss of balance:

● Movement of different body segments to relocate COM back to preperturbation (pre change of balance)
position
● Adjust the size of BOS

Stance postural control mechanisms for support:

Standing posture is vertical orientation. It is Unconscious
Small movements of COP reflect “good” balance

Postural Adjustments

1. Reactive (compensatory) balance control: ability to recover a stable position following an

unexpected perturbation. Feedback control ** something happens first then your body adjusts
(being pushed example)
2. Anticipatory postural control: adjustments are made in anticipation of voluntary movement that
is potentially destabilizing. Feedforward control ** thinking of movements before movement
occurs (example of standing on one foot)

Sensory systems involved in maintaining posture

1. Somatosensory

a. Cutaneous - touch
b. Proprioception - awareness of body position / body parts in space

2. Visual - reference for verticality, head motion (what is up and down) *** most impactful ***
3. Vestibular - position and movement of head with response to gravity

Anticipatory postural adjustments: motor cortex has already decided what it is going to do -

● Predict disturbances
● “Preprogrammed” central responses
● Can be modified with experience
● Occur ~50ms before voluntary movement.

○ Prevent destabilization of body during limb motion (leg or arm)

○ Reflects coordination of upper and lower limb muscles

Compensatory postural adjustments

● Depend on sensory feedback following loss of balance

● Rapid, stereotyped movements
● Can be modified with experience - with repeated exposure, response characteristics are refined

Sway: quiet stance: effect of sensory feedback

Anteroposterior: larger amplitude
Mediolateral: smaller amplitude

Response to perturbation

● Backward perturbation - passive forward sway (being pushed back you will adjust forward)
● Forward perturbation - passive backward sway (being pushed forward you will adjust backward)
Anterior posterior stability (when your feet are forward)

● Motor strategies: ankle, hip, step

Response to perturbation (anterior posterior)

● Ankle strategy: used when perturbation is small and support surface is firm
● Hip strategy: typically seen with large perturbation
● Step strategy: largest perturbation occurs

Perturbed stance: mediolateral stability

● Muscle synergy sequence: cephalocaudal

○ Head: movement in opposition to that of hip and ankle

○ Hip (20 ms later)
○ Ankle (40 ms later)

Implication for rehabilitation:

Quiet stance improved balance found with light touch (using finger and touching table example)
Repeated exposure to a given postural task causes subjects to refine their response characteristics to
optimize response efficiency.

Balance performance in autism: ARTICLE

ASD motor skills / balance can affect cognition skills ?!??

Posture in Aging

Spinal conditions of aging:

1. Spinal stenosis - abnormal narrowing of the body opening of the spine where the nerves exit.
2. Osteroporotic compression fractures
3. Degenerative spondylolisthesis- slippage of vertebrae forward and out of place most common in lumbar
spine
4. Degenerative joint disease

Falls in aging:

● Unplanned, unexpected contact with supporting surface

○ 33% of community dwelling seniors over the age of 65 fall each year
○ Females more often than males

Motor changes with aging

● Muscle fibers change and then muscles become smaller, cells die and are replaced with tissue and fat.
Causes change of muscle function
● Concentric motions affected more than eccentric motions/controlled movement back.
● ROM

○ Spinal flexibility declines with compensatory shift of COM backward toward heels
○ Ankle joint flexibility decreases between 55 and 85 yrs ( Females: 50% loss, Males 35% loss)

Comparison of older to younger adults:

■ Slower onset latency in ankle dorsiflexors (bringing toes/foot up)

 ■ Proximal mm activation before distal
■ Coactivation more common
■ Hip strategy used more often, ankle strategy less often than young adults

● Holding something in hands limits reach to aid balance

● Measurement of sway in quiet stance, eyes open, is not the best measure of balance

Sensory changes with aging

● Somatosensory

○ Decreased touch, discriminatory touch, pressure / vibration

● Vision

○ Contrast sensitivity (harder for them to see differences in surfaces/colors)

○ Cataracts, macular degeneration

● Vestibular

○ Loss of 40% of vestibular hair and nerve cells by 70 years

Balance changes with aging

● **Distortion, decrease or absence of 2 sensory inputs results in increased body sway, greater potential for
falls.***

Implications for rehabilitation:

● Balance can improve with practice

● Training in protective body mechanics may increase function
● Safety: older adults are more likely to fall during first trial of a new task -

Week 9: posture & balance in health aging / problems of posture and balance:

Assessment of spontaneous sway

● PD, Down’s, Cerebellar, CP, CVA all have increased sway

○ PD: increased sway and and velocity usually mediolateral

○ Down’s Syndrome: increased sway velocity
○ CP: increased sway
○ CVA: asymmetrical and increased sway

Impaired movement strategies: sequencing

1. Reversals in orderly recruitment of muscles

2. Delayed recruitment,with proximal mm first
- Down syndrome
3. Coactivation
- PD
4. Delayed activation of postural responses
5. Problems modifying postural strategies - difficulty selecting appropriate force response
6. Impaired stepping strategies - lack or delayed anticipatory lateral weight shift, leading to falls

Effects of sensory loss: Different types of tests to see sway index/ vestibular loss
 ● Eyes open, eyes closed, dome, eyes open on non firm surface, eyes closed on non firm surface, dome on
non firm surface.
● Loss of one sense is acceptable
● Loss of two or more senses: postural control is difficult

Effects of cognitive loss on stance:

1. “Balance second strategy”: balance tasks are prioritized after cognitive tasks. Task first balance
second - [PD and children with developmental coordination disability]
2. “Balance first strategy”: Balance is priority over other tasks. Balance is found then task is done -
[TBI / CVA / previous fallers]

Interventions:
Assessment: clinical questions - how confident are you that you can perform tasks, do you avoid activities because
of poor balance..
Assessment: postural balance - asking person to lean forward/ backward - observe and record compensations
Assessment: functional reach test - sideways to wall - reach and maintain balance test

Assessment: ABC scale (activities-specific balance confidence)

● Predicts potential for falls in persons with CVA -

● Person rates confidence in ability to carry out activities (0= not confident 100= very confident)

Neuro Article: motor strategies of postural control after stroke

- Weight-bearing asymmetry (WBA)

- Counteracting internal perturbations

1. Weight shifting ability & weight distribution

2. Limits of stability
3. Anticipatory postural adjustments

- External perturbations: external environment upsets someone sense of balance

- Conclusion: post stroke patients create motor strategy shifts to compensate

Berg Balance Scale (BBS)

● Minimal detectable difference (MDD) - smallest amount of change that can be detected by a measure that
corresponds to a noticeable change in ability
● Best single predictor of multiple fall status in community dwelling older adults without neurological
pathology

○ If < 36%, predictions for falling is close to 100%

Sitting balance: good prognostic indicator of outcome for people with CVA, TBI

● Impaired sitting balance on admission to rehabilitation unit associated with:

○ Dependence in locomotion and transfers at D/C and 1y post D/C

○ Next to age, ability to sit independently at admission is the best predictor of D/C FIM (functional
independence measure) scores

Interventions:

● Modify one of more of these to grade for improved balance

 ○ Speed, effort, degree of support, task complexity, environment

Week 10 - balance rehabilitation mobility

Sitting balance - good prognostic indicator of outcome for people with CVA, TBI

Improving balance: Interventions ** understand this and ways you can change these factors to make the task easier
or harder **

1. Speed
2. Effort
3. Degree of support
4. Task complexity
5. Environment

Standing Balance - to practice verticality. Static and dynamic balance

● Equal weight bearing

○ Use two weight scales

● Using a cane - increases in BOS

Retraining anticipatory balance control

● Safety is the first priority. Personal preference is second priority

● Less to more effort (sitting to standing to walking) (reaching to lifting to throwing)

Dual Task Cognition - impaired attention contributes to instability and falls.

● Non-motor dual-task of attentional control may improve balance in some but not all functional tasks
performed by older adults

Locomotion

Functional Gait: 3 essential requirements

1. Progression: movement is desired direction being able to start and stop movement
2. Stability: upright posture. Changing BOS of moving body.
3. Adaptability: meeting goals of the individual. Meet goals of the environment (obstacles)

Muscle Activation Patterns

1. Stance Phase: no movement.

- 60% of the time

- 20% double stance time
- Stability: Impact of initial contact, Propel body forward: push off with foot

2. Swing Phase

- 40% of the time

- Foot up in the air, swinging forward. Acceleration, momentum, deceleration, reposition leg.

Temporal and Distance Terminology

 ● Gait cycle: also known as stride length
● Velocity: average horizontal speed of body measured over 1+ strides
● Step length: distance from 1 footstrike to footstrike of other foot
● Stride length:distance from 1 footstrike to footstrike of same foot (two steps)
● Cadence:steps/min (unit of time)
● Step width:distance from outside of one foot to outside of other foot
● SLS: single leg stance
● DLS: double leg stance

Young Adult Locomotion: preferred step rate minimizes energy requirements

Walking Speed

● To increase walking speed: increase step length and frequency

● To decrease walking speed: increase stance time

Central pattern generation (CPGs): rhythmic stereotyped movement (walking, swimming, respiration)

● Supraspinal input allows greater locomotor variability in response to task and environmental conditions.

Somatosensory Contributions

1. Reactive adaptation - trips, slips

2. Proactive adaptation - anticipate disruptions in gait and modify. Predicts changes/ avoids problems

Sensory Feedback and locomotion:

- Feedback: visual, vestibular, somatosensory

- No feedback : step cycle is longer and stereotyped

Proactive use of vision:

● Increased optic flow (visual flow) from the environment helps to determine our speed / align body to
gravity
● Visual sampling of environments helps to identify obstacles.

○ Even terrain is visually sampled for 10% of travel time

○ Visual sampling Increases to 30% of travel time for uneven terrain / precise foot placement

● Central vision is primarily used; peripheral vision helps with obstacle crossing

Reactive Accomodation to vision: walking on slippery surfaces - slower stand duration, shorter stride lengths,
slower velocity….

Sequence of avoidance strategies:

1. Change placement of foot - complex and task specific

2. Increase ground clearance
3. Change direction of gait when obstacles can’t be cleared

a. Spin-turn: turn to right with right foot in front, “spin” of right foot
b. Step-turn: turn to left with right foot in front

4. Stop

Recovery from balance threats:

 ● Slips
● Trips

Adaptive control in aging:

1. Proactive (anticipatory) adaptation

■ 2 step lengths needed for change, vision decreased

2. Reactive adaptation

■ Trips - 37 - 45% of falls in older adults are due to trips

■ Slips - 27 - 32% of falls in older adults in community

Stairs and Aging

● Largest percentage of falls in public places

○ 4 / 5 during descent

● Negotiation requires

○ Force: concentric on ascent, eccentric on descent

○ On ascent, forces are 2x greater than walking

Gait Patterns

● Neurogenic claudication: pain with ambulation, less when walking uphill more with downhill
● Crouch gait: excessive flexion at hip, knee, and ankle. energy- inefficient gait.
● Parkinsonian Gait: rigid body with decreased arm swing. Trunk flexion. Protracted shoulders
● Hemiparetic Gait: spastic gait (stiffed legged gait) circumduction when walking and toe is down.

Article Gaits:
waddling gait - (myopathic gait) weakness in pelvic girdle
steppage gait - inability to lift the foot while walking due to weakness in muscles that cause dorsiflexion of
ankle joint
parkinsonian gait - shuffling gait. Feelings of being stuck in one place when initiating step or turning
cerebellar ataxic gait - widened base, unsteadiness and irregularity of steps, and lateral veering.
functional gait disorder - abnormal movement of part of the body due to a malfunction in the nervous
system.
For these gaits ^^ How does it appear? What does it look like. - be able to describe it. What are the probably causes
(neurophysiological mechanisms)

Sit to stand:

● 2-4 phases:

○ Weight shift or flexor momentum

○ Horizontal and vertical motion of body
○ Extension at hips and knees
○ Stability

Supine to stand
 ● No one pattern is used by all. 3 common strategies

○ Asymmetric movement of extremities and axial region + symmetrical squat

○ Asymmetric squat on rising
○ Asymmetric use of arms, partial axial rotation, assumption of stance from half-kneel position

Rising from Bed: patterns used are extremely variable

Rolling: Assumption: is shoulder and pelvis should always rotate in unison (bobath)

Posture and Balance - Mobility Lab

Delineate between the OT and PT scope of practice, as it relates to mobility, balance, gait, and functional
ambulation - OTs do not address remediation of gait impairments or progress gait mobility devices - OTs address
functional ambulation in the direct context of occupations and do more occupational analysis.
3 person factors that influence balance - vision, somatosensory function, and vestibular
Demonstrate appropriate method of “sizing” a cane or walker for a client. Wrist height with 20-30 degrees of
flexion (25 degrees is best)

_____________________________________________________________________________________________

Week 12: Aphasia, Hemispatial neglect, & visual field deficits

Aphasia: an acquired communication disorder that impairs a person’s ability to process language, but does not
affect intelligence.
Causes: stroke, TBI, and ABI as well as PPA (primary progressive aphasia)
27 different classifications, including Wernicke’s & Broca’s

Temporal lobe damage:

Left hemisphere: - language deficits: verbal and written
Anterior: Broca’s area
Posterior: Wernicke’s area
Ideational apraxia
Difficulty remembering steps to a process, lists, numbers, facts, data.
Right hemisphere: non-verbal language deficits (understanding tones and influx in voices)
Anosognosia - decreased awareness of deficits
Impaired visuospatial memory (ex: remembering directions)
Categorization of Aphasia:

● Fluent: ex. Wernicke’s aphasia (words and tone are good but words are not coming out correctly)
● Non-fluent: ex. Broca’s aphasia (words are difficult to speak and get out)
● Differential diagnoses: dysarthria, cognitive impairment, hearing impairment, dysphagia (swallowing)
● SLP typically diagnoses and treats

OT Role: Individuals with Aphasia

Complete a thorough chart review
Collaborate with SLPs
Adjust OT sessions to support communication and participation.

Supported communication for Aphasia:

● Reduce distractions, take it slow one topic at a time, monitor non-verbal communication, use multimodal
cues and gestures, treat in a familiar context, use environmental support
 ● Monitor your verbal and written communication: give options, field of 2 or field of 3
● Empathize: say things like “i know that you know”

Hemispatial Neglect:

● Multimodal disorder of cognition (attention and awareness)

● Most common after brain injury to R hemisphere
● Neurological vs. psychological - both can mean “failure to attend”
● Characterized by inattention to one side of the body or environment

1. Personal neglect: body awareness

2. peri-personal : immediate spatial awareness
3. Extrapersonal: environmental neglect

Hemispatial Neglect - pathophysiology

● Disrupted integration between multiple brain regions:

● Size and depth of lesion directly proportional to # of affected structures, severity of neglect

○ Temporoparietal junction, inferior frontal gyrus, superior temporal gyrus, medial frontal cortex,
thalamus, basal ganglia, white matter.

Parietal Lobe Damage: Right hemisphere

● Visual-spatial impairments, L spatial neglect, impaired spatial orientation, apraxia, non-verbal or visual
memory

Parietal Lobe Damage: Left hemisphere

● Acalculia, ideational apraxia, R spatial inattention, impaired L/R discrimination, impaired recognition of
objects, agraphia

Hemispatial neglect reflects not only damage to specific brain regions, but also large-scale networks of the brain
devoted to: attention, motor, multimodal sensory processing, including visual and auditory processing
OT role: facilitate sensory input to the affected side.

Visual field deficits (VFD):

Sometimes referred to as visual field “cuts”
Typically occur after damage to the visual pathway
Can see losses to both central and peripheral fields

Occipital Lobe Damage:

Left homonymous hemianopsia / right homonymous hemianopsia
Visual agnosia
Cortical blindness

Visual field and attention:

● Central field: the :what” of vision.

● 0 - 30 degrees
● Detail oriented and color vision
● Object identification
● Mostly cone receptors

VFD - Functional Impact

 ● bumping/colliding into things on the side of field loss
● Missing items on side of field loss
● Slow visual scanning to affected side
● “Stair step” saccadic pattern when completing visual search

OT and Vision

● OTs evaluate for visual dysfunction as a means to explain occupational limitations

● OTs can describe a patient's functional changes or implications
● Work to increase a person’s participation in relevant and meaningful activities
● Screen not diagnose
● Collab with neuro optometrist

Comparing VFD with Neglect

● Visual field deficit:

○ Visual processing is cause

○ Abbreviated search pattern with omissions
○ Visual search pattern organized and improved with cues
○ Checks tasks and accuracy
○ Easier to increase awareness

Hemispatial Neglect:

● Vision is byproduct of cog impairment

● Abbreviated search pattern with omissions

Week 13: Reach/Grasp/Manipulation

Locating a target: eye-head-trunk coordination:

● Eye movement: first movement that occurs; shortest latency

● Head movement: occurs 20-40 ms before eye movement but, bigger muscles take longer to move which is
why eyes move first
● Trunk movement

Reaching to objects in a far visual field:

● Train these areas separately and specifically (eyes, head, and trunk control)
● When each is training separately, train combining areas
● Use the hand to follow smooth pursuit

Prehension - “act of taking hold”

Two separate motor commands that must be coordinated

1. Reach (transport phase) 2. Grasp (aperture formation)

Components of reach and grasp:

● Arm - controls general placement in space

● Wrist - precise hand placement with object
● Thumb - doesn’t move for object contact
● Fingers - widen for object contact
Arm movement Kinematics: Position
Bell shaped time symmetric velocity profile regardless of distance moved

Visually controlled reaches

Grasp and throw -
Contralateral reaches slower and less accurate
Ipsilateral reaches start more quickly, more accurate

Neural control of reach and grasp

Neural systems involved - sensory systems, M1, premotor cortex, posterior parietal lobe, cerebellum

Somatosensory contributions to reach

● Suggests that kinesthetic feedback not required, that a central motor program is involved
● Similar performance as longa s movements are well-learned, simple and not repetitive

There is a separate descending pathway each for Reach and Grasp!

GRASP

Grasp patterns:

● Power versus precision grips (full hand tight grasp vs pinches)

● Prior knowledge help shape hand for grasp

○ Use common and familiar objects

○ Object used drives the muscle used, the muscle sequence, and the amount of force required

● Requirements for successful graph

○ Hand must adapt to object

○ Fingers must close at appropriate time

Somatosensory contributions to grasp:

Cutaneous afferent input triggers grasp response

Anticipatory control of grasp patterns: precision grip formation

● Grasp forms during transportation phase of reach

● Pregrasp hand shaping depends on:

○ Intrinsic properties
○ Extrinsic (contextual) properties of object

Grasp aperture formation:

● Maximum aperture

○ Occurs during deceleration of transport phase (bell curve

○ Increases with increasing object size
○ Increases if vision is unavailable
○ Increases with increasing ended point variability
○ Increases with speed of transport phase
Requirements for a successful grasp:

● Shaping of hand during transport

○ 70-78 percent of movement time (Jeannerod)

○ Thumbs stays in position; fingers change
○ Fingers increase then decrease to object size

● Hand must adapt to object

● Fingers must close at an appropriate time.

Grasp & neurological deficits:

● Reaction time delayed, inflections during rise time, grasp force might not mirror each other
● Absolute peak force may or may not be early in profile
● Peak forces of right and left hand may not be synchronous
● Increased variability in maintenance phase
● Drop time is delayed
● BOTTOM LINE: Grasp force stability with objects is limited and variable

Atypical movement patterns: lack of individuation (ability to make isolated motions of individual joints or body
segments)
Study: with hemiparesis, worse performance on a reach-out than a reach-up task

● Global synkinesis or motor irradiation: involuntary and unintentional movement of a limb when the other
limb is active.

= mirror movements (due to bilateral activation and inability to inhibit opposite hemisphere by
transcallosal neural fibers.

Atypical movement in reach and grasp:

Problems moving the Hemiplegic UE:

● Movement times are significantly longer

● Movement amplitudes are smaller
● Trajectories show

○ Segmented movements
○ Increased variability
○ Disrupted interjoint coordination
○ Not smooth end point trajectories

● Lack of coordination between shoulder and elbow

○ Limitation of AROM of these joints with hypometric movement

● Severity of spasticity correlated with 1. Movement time 2. Amplitude

Deficits in reaching with hemiplegia:

● BOTTOM LINE: Deficits in joint individuation are the primary problem affecting impaired reaching in
persons with CVA.
● Research found increased activation of all muscles, especially lateral and anterior deltoid
● BOTTOM LINE: Inability to generate sufficient force in paretic arm mm leads to additional muscle
activation to accomplish the task.
Problems with grasp:

Hemispheric specialization affects reach and grasp

● Left hemisphere is specialized for visuomotor transformation - grasp preshaping

● Right hemisphere is specialized for transport-grasp coordination

Recovery of reach and grasp following CVA

● Majority of recovery occurred by 90 - days post onset, with little recovery occurring between the 90 - day
time point and one year.

Deficits in reach and grasp with PD

● Bradykinesias may be task dependent

○ More present when reaching for a station object that a moving one

● L-dopa improves reach more than grasp

● Grasp is more affected than reach

Sensory deficits and precision grip

● Lesions of posterior parietal lobe - impaired somatosensation

● Bottom line: posterior parietal cortex is important in organizing object-oriented action.

Impaired anticipatory control of precision grip:

● Left hemisphere (right hemiplegia) is responsible for anticipatory grip force scaling for lifting common
objects
● Rehabilitation: practice with left less affected side then practice with affected right side to improve
grasping behavior

Interlimb coupling and bimanual tasks

● Rehabilitation: practice with bilateral reach may be beneficial

Timing problems in reach: delayed movement time in CVA, CP, CB, PD

Atypical movement patterns:

● Synergy: two definitions

○ Within normal movement

○ Within abnormal movement (as in CVA): fixed patterns of movement involving the entire limb,
with an inability to isolate movement outside of the synergy.

Article: movement based priming: clinical application and neural mechanisms

● Prepping brain for movement - unilateral, bilateral, and aerobic priming

● Work before task specific training in repetitive movement that is not skill based, non functional
● “Brain warmup” - like wrist extension/flexion
● Should prime muscles and brain before tasks ~ 20-30 minutes

Week 13.1. Vision lab:

 - Work to increase a person’s participation in relevant and meaningful occupations - This is key to recovery
and facilitating neuroplasticity. OTs role is to screen not diagnose

3 questions to remember: when was the last time you saw an eye doctor, do you wear glasses, how is this affecting
your vision/ you
Visual acuity: clearness - resolution and power of the eye, ability to see clearness and clarity of vision
20/40 acuity or worse indicated need for referral
Pupillary responses
Pursuit vs fixation - oculomotor range of motion - searching for object then finding it and focusing on it
Convergence vs divergence - eyes coming together (like to read) & eyes coming apart
saccades - following two different stimuli (colors) “jumping” between the two
Homonymous hemianopsia:

Week 14: Hemiplegia: neuroscience concepts on intervention

Project takeaway: intensive, repetitive and focused exercises resulted in improved hand function
All participants improved in grasp force parameters, clinical measures and hand function.

Problems with Hemiplegia:

- BOTH sides are affected

- Better to say “less affected” than “unaffected” or “good”

Assessment of potential for recovery

- Active finger extension: indicates viable motor cortex and corticospinal function

Principles of intervention:

● Motor learning:

○ For adaptive neuroplasticity, motor learning must occur: meaningless repetition of well-learned
tasks does not promote adaptive neural change
○ Attention and motivation are required: challenging and stimulating.

● The Person:

○ Impaired motor control, at least in part, is due to underlying muscle weakness

○ There is an optimal window of time for recovery during which neural modification is most easily
achieved

● The environment:

○ Allow increased opportunities for active movement and spontaneous as well as increased social
engagement
○ Consider the temporal environment; only a small percentage of time is spent in formal
rehabilitation each ay

● The Task

○ Use real and common objects because the object drives temporal sequences of muscle
activation, hand shaping, development of appropriate force

● Repetitive Task Training (RTT) Repetitive Specific Training (RST)

○ Task based training leads to adaptive neuroplastic reorganization

 ○ ADL activities in addition to exercise may be more beneficial than exercise alone

● Repetitive and focused tasks

○ repetition , specifically focused and task-oriented tasks are required: repetitive but nonspecific
intervention resulted in a small overall improvement but without improvement of the affected
limb.
○ Intense repetitive exercise of the affected hand was more effective than NDT

● Repetition

○ Current therapies do not provide enough repetition.

○ Observation of OT/PT neurorehabilitation sessions in an outpatient setting

■ 36 min per session. 34-39 reps active and passive

■ 12 reps purposeful
■ 3 repetition sensory stimulation

Exemplar Research Studies:

● Purpose: Demonstrate efficacy of RTT on kinematic movements of UE and spasticity.

● Participants: Children and teens with hemiplegia. Most had cerebral palsy.

○ 3 groups
○ Intervention for 30 min twice daily, 5 times per week
○ Intervention for 30 min three times a week
○ Social interaction for 30 min three times a week

● The intervention was provided by Kinesiology students at the UM following training in RTT by Dr. Conti

○ Intervention most commonly included use of straight-line trajectory during activities of interest to
the participant

● Movement: shoulder abduction 0 degrees / shoulder abduction 90 degrees. (2 joints)