REVIEW OF LITERATURE

Divya Shanthi S
1st Year MPT
Department of
Neurophysiotherapy
MOTOR CONTROL
THEORIES
Motor Control
• Motor control is defined as the ability to regulate or direct the mechanisms essential to
movement.
• Movement emerges from the interaction of three factors: the individual, the task, and the
environment.
• The individual generates movement to meet the demands of the task being performed within a
specific environment.
Factors that constrain movement:
Individual: Action, perception and cognition
Task: Mobility, stability and manipulation
Environment: Regulatory and nonregulatory
Movement arises from the interaction of perception and action systems, with
cognition affecting both systems at many different levels
 THEORIES
Reflex Theory

• Sir Charles Sherrington, a neurophysiologist proposed this theory.

• According to Sherrington, reflexes were the building blocks of complex behaviour and
complex behaviour could be explained through the combined action of individual reflexes that
were chained together.
Limitations of Reflex theory:
1. The reflex cannot be considered the basic unit of behaviour if both spontaneous and voluntary
movements are recognized as acceptable classes of behaviour, because the reflex must be
activated by an outside agent.
2. Does not adequately explain and predict movement that occurs in the absence of a sensory
stimulus.
3. The theory does not explain fast movements, that is, sequences of movements that occur too
rapidly to allow for sensory feedback from the preceding movement to trigger the next.
4. The concept that a chain of reflexes can create complex behaviours fails to explain the fact
that a single stimulus can result in varying responses depending on context and descending
commands.
5. Reflex chaining does not explain the ability to produce novel movements.
Clinical implications:
• A patient’s movement behaviours would be interpreted in terms of the presence or
absence of controlling reflexes. Retraining motor control for functional skills would
focus on enhancing or reducing the effect of various reflexes during motor tasks.
 Hierarchical Theory:
• Hughlings Jackson, described higher, middle, and lower levels of control equated with higher
association areas, the motor cortex, and spinal levels of motor function
• Hierarchical control in general has been defined as organizational control that is top down. Each
successively higher level exerts control over the level below it and there is no bottom up
control.
• In 1920’s Rudolf Magnus found that reflexes controlled by lower levels of the neural hierarchy
are present only when cortical centres are damaged. These results were later interpreted to
imply that reflexes are part of a hierarchy of motor control, in which higher centres normally
inhibit these lower reflex centres.
• In 1928, Georg Schaltenbrand by using concept of Magnus explained development of mobility
in children and adults.
• In 1938, Stephan Weisz described the development of equilibrium reflexes and relationship
between maturation of these reflexes to child’s ability to sit, stand and walk.
• Neuromaturational theory of development
 Limitations :
• Hierarchical theory cannot explain the dominance of reflex behaviour in certain situations in
normal adults such as steeping a pin results in immediate withdrawal of leg which is a bottom
up control.
Clinical implications:
• Brunnstrom, who pioneered early stroke rehabilitation, used a reflex hierarchical theory to
describe disordered movement following a motor cortex lesion. She stated, “When the influence
of higher centres is temporarily or permanently interfered with, normal reflexes become
exaggerated and so called pathological reflexes appear”
• Bobath about abnormal postural reflex activity in children with cerebral palsy, stated that “the
release of motor responses integrated at lower levels from restraining influences of higher
centers, especially that of the cortex, leads to abnormal postural reflex activity”
 Motor Programming theory:
• The term motor program is for central pattern generators, a specific neural circuits(spinally
mediated motor programs) by which patterned motor response can be obtained by removal of
stimulus or afferent input.
• Early 1960’s experiment by Wilson on grasshopper supported this theory
• In 1980, Grillner’s experiment on locomotion of cat also supported this theory.
• Higher level motor programs represent action in abstract terms. ex: rules for
writing a given word.
 Limitations
• CPG expanded understanding of the role of the nervous system in movement control but can not
replace importance of sensory stimuli in movement control
• Motor program concept does not include musculoskeletal and environmental variables in
achieving movement control.
Clinical implications:
• Explanation of abnormal movement is expanded to include problems resulting from
abnormalities in CPG or in higher level motor program.
• Motor program theory suggests the importance of helping patients relearn the correct rules for
action. Intervention should focus on retraining the movements of functional task along with re-
educating specific muscles in isolation.
System Theory
• This theory was proposed by Nicolai Bernstein.
• Bernstein looked whole body as a mechanical system. External forces (gravity) and internal
forces (inertial and movement dependent forces) acting on body is important along with neural
control of movement.
• Bernstein first proposed the concept of degrees of freedom that needs to be controlled and said
that coordination of movement is the process of mastering the redundant degrees of freedom of
the moving organism.
• Hierarchical control exists to simplify the control of the body’s multiple degrees of freedom.
The higher levels of the nervous system activate lower levels. The lower levels activate
synergies or groups of muscles that are constrained to act together as a unit.
• In 2007, Latash et al proposed definition of degrees of freedom
Limitations:
• Interaction with environment was not focused
Clinical implications:
• When working with the patient who has a CNS deficit, the therapist must be careful to examine
the contribution of impairments in the musculoskeletal system and neural system to overall loss
of motor control.
Dynamic system theory
• Dynamic systems theory is based on the self organization principle.
• This principle states that when a system of individual parts comes together, its elements behave
collectively in a ordered way without need of higher centres commands.
• Non linear behaviour: new movement emerges from critical change in one of the systems called
control parameter
Control parameter: Variable that regulates change in behaviour
• Attractor state are highly stable behaviours and are preferred pattern of behaviour used to
accomplish common activities of daily life
• Attractor well: The degree to which the flexibility exists to change a preferred pattern of
movement
• Kelso and Tuller shown that the stable movements become more variable, or unstable, just prior
to a transition to a new movement pattern.
Changes in linear dynamic behaviour of moving system
Limitations
• The presumption that the nervous system has a less important role in determining the animal’s
behaviour and body mechanics a more dominant role in describing motor control.
Clinical implications:
• Shifts or alterations in movement behaviour can often be explained in terms of physical
principles rather than necessarily in terms of neural structures.
• As variability is viewed as a critical element of normal function, therapists will encourage
patients to explore variable and flexible movement patterns that will lead to success in
achieving performance goals
Ecological theory
• James Gibson focused on how we detect information from environment that is relevant to our
actions and use this information to control movements to perform goal directed behaviour.
• Perception focuses on detecting information in the environment that will support the actions
necessary to achieve the goal.
• The ability to use perceptions to guide action emerges early in life
Limitations:
• This theory gave less emphasis to the organization and function of the nervous system that led
to this interaction of organism and environment.
Clinical implications :
• Individual as an active explorer of the environment where task is performed allows him to
develop multiple ways to accomplish task. During intervention this help patient to know and to
find adaptive solutions for performing functional task.
Equilibrium Point Hypothesis

• Described by Feldam.
• Fundamental concept for this theory is threshold position control.
• To perform intentional activities, electrochemical influences descending from the brain in the
presence of proprioceptive feedback to motor neurons are transformed by changes in the
threshold(control signal) to muscle lengths or joint angles at which these motor neurons begin
to be recruited.
• If the length of muscle is below threshold, muscle is silent. If it is over threshold, the muscle is
activated and the level of activation grows with the difference between the actual muscle length
and the threshold value. This activation tends to produce muscle shortening(contraction)
bringing the length closer to the threshold value.
TITLE
Assessement of correlation between gait
speed in post stroke patients and the time
from stroke onset, the level of motor
control in the pareitic lower limb
proprioception
Authors: Mariusz drusbicki et al
Journal: advances in rehabilitation
2016
METHODOLOGY
Retrospective study
Study consisted of 600 patients after first
stroke who walked independently.
The measurements were gait speed
assessed by 10m walk test, motor control
in LL according to brunnstrom recovery
stages, proprioception in LL, visual fields
and functional independence by Barthel
index.
CONCLUSION
Gait speed was strongly correlated with
motor control in the LL and impaired
proprioception
Revealed negative correlation between
gait speed and subject’s age.
No correlation between gait speed and
time from stroke onset.
Gait speed and functional independence
were significantly correlated
The level of motor control in the paretic
lower limb and proprioception are vital
factors affecting gait speed and functional
independence.
Patients with a higher level of functional
independence demonstrated higher gait
speed.
TITLE METHODOLOGY CONCLUSION
Applying Motor-Control Theory to Case report This case report demonstrates a means by
Physical Therapy Practice: A Case Report Patient was a 5-year-old boy with spastic which current knowledge and theory can
Authors: Lisa K. Kenyon, Mary T. hemiplegic cerebral palsy who was be integrated into clinical practice
Blackinton entering kindergarten. Parent concerns When the child entered kindergarten, he
Journal: Physiotherapy Canada related to the child’s safety in playground was able to safely ascend the ladder to the
Volume 63 activities such as playing on the slide playground slide, using a modified
Number 3 environmental distractions were movement pattern, when distractions
Year: 2011 minimized by controlling the setting and were minimized.
the number of people in the treatment
area task demands were modified
activities were consistently modified.
Later for each task bell was rung so that
the activities are done in sequence.
All activities were made into games and
play.
TITLE
Characterization of motor control in
handwriting difficulties in children with
or without developmental coordination
disorder
Authors: Shao-hsia chang and Nan-ying
yu
METHODOLOGY
Seventy-two children with handwriting
deficits (33 with DCD, 39 without DCD);
and 22 age- and sex-matched children
without handwriting deficits were asked
to perform handwriting tasks on a digital
tablet for the collection of kinematic and
kinetic data. Practice times required to
achieve automation of movement when
writing an unfamiliar character were used
to assess the motor learning of
handwriting. The children were asked to
copy three simple and three complex
characters, and the velocity and axial pen
force used for corresponding strokes were
compared
CONCLUSION
The attainment of automated handwriting
was markedly slower in children with
handwriting deficits and DCD.
By linking the results with neuromotor
control theories, it was determined that
children with DCD have difficulties
performing the open-loop and closed-loop
movements required for fluent
handwriting.
TITLE METHODOLOGY CONCLUSION
The Effects of Bilateral Arm Training on Randomized controlled trial Relative to CI, BAT improved the
Motor Control and Functional Pretreatment and posttreatment measures spatiotemporal control of the affected arm
Performance in Chronic Stroke: A enrolled in both bilateral and unilateral tasks, and
Randomized Controlled Study 33 stroke patients 6 to 67 months after reduced motor impairment. These
Authors: Keh-chung Lin, Yi-an Chen, onset of a first stroke were included in findings support the use of BAT to
Chia-ling Chen, Ching-yi Wu, and Ya-fen study. 16 subjects received BAT program improve motor control and motor
Chang concentrating on both upper extremities function of the affected upper limb in
Journal: Neurorehabilitation and Neural moving simultaneously in functional stroke patients.
Repair tasks by symmetric patterns and 17
Volume:24 received CI (control treatment) for 2
Issue:1 hours on weekdays for 3 weeks.
Pages: 42 –51 Outcome measures: Kinematic analyses
Year: 2010 assessing motor control strategies for
unilateral and bimanual reaching and
clinical measures involving the Fugl-
Meyer Assessment (FMA) of motor-
impairment severity and the Functional
Independence Measure (FIM) and the
Motor Activity Log (MAL) evaluating
functional ability.
TITLE METHODOLOGY CONCLUSION
Comparison of Motor Control Deficits Individuals with chronic hemiparesis (56) Persons, both healthy and poststroke,
During Treadmill and Overground and similarly aged healthy individuals walk with different gait parameters on the
Walking Poststroke (17) walked over an instrumented TM. Although measures of motor control
Authors: Steven A. Kautz, Mark G. walkway and on an instrumented split- were mostly similar between the 2
Bowden, David J. Clark and Richard R. belt TM. 16 channels of EMG recorded environments, the TM induced step length
Neptune bilateral muscle activity, and a 12-camera asymmetry in 30% of participants (60%
Journal: Neurorehabilitation and Neural motion capture system collected bilateral of whom took longer paretic steps). TM
Repair 3D kinematics. Nonnegative matrix walking, therefore, is a valid method for
Volume:25 factorization (NNMF) algorithm were detecting motor control deficits.
Issue: 8 applied to examine the underlying
Pages: 756 –764 patterns of motor control.
TITLE
Understanding Adaptive Motor Control
of the Paretic Upper Limb Early
Poststroke: The EXPLICIT-stroke
Program
Authors: Joost van Kordelaar, Erwin E.
H. van Wegen, Rinske H. M. Nijland,
Andreas Daffertshofer and Gert Kwakkel
Journal: Neurorehabilitation and Neural
Repair
Volume:27
Issue: 9
Pages: 854 –863
Year : 2013
METHODOLOGY
Thirty-one patients with a first-ever
ischemic stroke were included. Repeated
3-dimensional kinematic measurements
were conducted at 14, 25, 38, 57, 92, and
189 days poststroke. Trunk, shoulder,
elbow, and wrist rotations were measured
during a reach-to-grasp task. Using
principal component analysis the
longitudinal changes in dissociated upper
limb movements during reach-to-grasp
were investigated. Twelve healthy
subjects were included for comparison.
CONCLUSION
Motor control by dissociation of shoulder
and elbow movements occurs mainly
early poststroke. However, compared
with healthy adults, most patients did not
achieve fully dissociated upper limb
movements at 26 weeks poststroke,
suggesting that upper limb motor control
after stroke remains adaptive.
CLINICAL PRACTICE
Neurologic rehabilitation: Reflex based neurofacilitation
approach
• Assumptions drawn from both reflex and hierarchial theories of motor control lead to
development of neuofacilitation approach such as:
1. Bobath approach
2. Rood approach
3. Brunnstrom approach
4. Proprioceptive neuromuscular facilitation approach
5. Sensory integration therapy
• These techniques focused on retraining motor control through techniques designed to facilitate
the normal movement pattern and inhibit abnormal movement patterns
• Repetition of normal movement pattern will automatically transfer to functional tasks
TITLE
Effects of a training program based on the
Proprioceptive Neuromuscular
Facilitation method on post-stroke motor
recovery: A preliminary study
Journal: Journal of bodywork and
movement therapies
Volume:18
Pages: 526-532
Year: 2014
METHODOLOGY CONCLUSION
Eleven individuals with chronic The results indicated that the program
hemiparesis after unilateral and non- resulted in improvement of motor
recurrent stroke underwent training based function and functionality, suggesting that
on PNF method for twelve sessions, being this program may be beneficial for these
evaluated for motor function - using the outcomes, although PNF does not seem to
Stroke Rehabilitation Assessment of be effective for restoring hemiparetic gait.
Movement (STREAM) instrument;
functionality, by the Functional
Independence Measure (FIM); and gait
kinematic (using the Qualisys Motion
Capture System), at baseline and post-
training
TITLE
Comparison of Brunnstrom movement
therapy and motor relearning program in
rehabilitation of post-stroke hemiparetic
hand: A randomized trial
Authors: Shanta Pandian, Kamal Narayan
Arya and E. W. Rajkumar Davidson
Journal: Journal of bodywork and
movement therapies
Volume: 16
Issue: 3
Pages 330-337
Year: 2012
METHODOLOGY CONCLUSION
Randomized trial BHM was found to be more effective than
30 post-stroke subjects were randomly MRP in rehabilitation of the hand in
assigned into two equal groups (Group A chronic post-stroke patients.
and Group B). Group A received
Brunnstrom hand manipulation (BHM).
BHM is the hand treatment protocol of
the Brunnstrom movement therapy, which
uses synergies and reflexes to develop
voluntary motor control. Group B
received the Motor Relearning Program
(MRP) based hand protocol. MRP is the
practice of specific motor skills, which
results in the ability to perform a task.
Active practice of context-specific motor
task such as reaching and grasping helps
regain the lost motor functions.
Outcome Measures: Brunnstrom recovery
stages of hand (BRS-H), FugleMeyer
assessment: wrist and hand (FMA-WH)
TITLE
Comparison of motor relearning program
versus bobath approach at every two
weeks interval for improving activities of
daily living and ambulation in acute
stroke rehabilitation
Authors: Gajanan Bhalerao, Vivek
Kulkarni, Chandali Doshi, Savita
Rairikar, Ashok Shyam
Journal: International Journal of Basic
and Applied Medical Sciences
Volume: 3
Issue: 3
Pages: 70-77
Year:2013
METHODOLOGY
Randomized Control trial
32 subjects with first unilateral stroke
(middle cerebral artery territory
involvement) were included in the study.
Random allocation using block
randomization in to two groups was done.
Group A included 17 subjects received
Motor Relearning Program (MRP) and
Group B, 15 subjects received
management based on Bobath approach
for a period of six weeks. Functional
Independence Measure and Barthel Index
used for ADL’s assessment and
Functional ambulation category and
Dynamic gait index for ambulation
performance
CONCLUSION
Motor Relearning program was effective
than BOBATH approach in early
enhancement of Activities of Daily Living
(ADL’s) and ambulation when compared
at every two weeks interval in Acute
Stroke Rehabilitation in first six weeks of
training.
Clinical significant- Thus MRP approach
can be used in early phase of
rehabilitation for improving activities of
daily living and ambulation as it involves
daily task specific activities, which are
required for ADLs & thus it helps in
getting good co-operation from patients.
TITLE METHODOLOGY
Sensory integration and activities of daily Randomized control trial
living in children with developmental 37 cases with developmental coordination
coordination disorder disorder and 35 healthy age-matched
Authors:Bulent Elbasan, Hlya Kayihan peers were included in this study. Ayres
and Irem Duzgun Southern California Sensory Integration
Journal: Italian journal of pediatrics Test was used for evaluating the sensory
Volume: 38 integration and Functional Independence
Issue:14 Measure for Children (WeeFIM) was used
Year:2012 for evaluating the activities of daily
living.
CONCLUSION
somatosensory perception tests,
significant differences were found in
kinesthesia, manual form perception,
finger identification, figure-ground
perception, localization of tactile stimuli,
double tactile stimuli perception (p <
0.05). Control group was better in motor
planning (p < 0.05). Comprehension,
expression, social communication,
problem solving, and memory skills were
significant in favor of the control group (p
< 0.05). Graphestesia and self-care
domain was found to be correlated (r =
0,491, p = 0.002) between the groups.
Task oriented approach:
• Abnormal motor control suggest that movement problems result from impairments within one
or more of the systems controlling movement.
• In motor cortex lesion, the behaviour observed is not just the result of the lesion itself, but also
of the efforts of the remaining systems to compensate for the loss and still be functional. So the
goal in intervention is to improve the efficiency of compensatory strategies used to perform
functional tasks.
• In task-oriented approach, intervention assumes that patients learn by actively attempting to
solve the problems inherent in a functional task rather than by repetitively practicing normal
patterns of movement
THANK YOU