Table of Contents
Issues are seen and the skills affected
Intervention or lesson plan
The central nervous system and peripheral nervous systems of a human include brain, spinal cord and the nerves which are afferent and efferent to and from them are complex in structure and function. It is responsible for many things including the motor control of the human movement which varies from a loop reflex which is simple to a network of patterns which is complex in nature. The aim of the present proposal is to discuss the motor control theory with respect to the population that is selected in relevance to the specific skill that requires enhancement. The proposal mentions the detailed intervention or lesson plan and the method of assessment for the given population.
Stroke is a cerebrovascular accident which can occur due to various reasons and is responsible for one of the leading causes for disability across the globe and people often loses their jobs because of their inability to work due to their disability (Hatem et al., 2016). The world health organization has predicted that the incidence of stroke is likely to increase by 30% between the years 2000 to 2025 (Hatem et al., 2016). Stroke is defined as the sudden death of brain cells which attributed to the lack of oxygen to a part of the brain which can be due to blockage in the artery supplying blood to the brain or due to rupture of an aneurysm or rupture of a blood vessel in the brain (Coupland et al., 2017).
Brain cells require oxygen to function and the delay in oxygen leads to the death of the brain cells and immediate intervention is required if not there can be cognitive and motor impairment in the patient. It can cause sudden loss of speech, weakness or paralysis which is the most common clinical representation of stroke as rarely medical management is provided and the destruction often occurs. Contralateral side of the body is the one which loses its motor function when there is stroke and upper extremity's motor impairment is the one which is most commonly seen and due to non-use it leads to muscle weakness or contracture, reduced tonicity of the muscle, and laxity of the joint (McLoughlin, 2018). Neurological recovery is not related to motor recovery but the latter is affected by the former. Upper extremity motor function rehabilitation should be done by global motor rehabilitation, stimulation of the brain, hemispheric sub-specialization and multisensory interaction (Hatem et al., 2016).
For the current proposal, motor control theory will be taken for the improvement of voluntary function in upper extremity paralysis due to the death of brain cells in patients who have suffered a stroke. Motor control theory is not merely related to the movement but it is complex and is related to the psychology, cognitive science, biomechanics and neurosciences (Fridland, 2017). Motor control theory is related to the practice of movement which is goal-directed in such a way that it is helpful in the achievement of function which is related to the skills that are decided upon like reflexive, automatic, adaptive and voluntary (Fridland, 2017).
There are various motor control theories and the clinical implications vary as per the theory that is selected. For the given proposal that theory that is most appropriate is the hierarchical theory in combination with motor programming theory as the population selected is of patients who have suffered from a stroke and have upper extremity paralysis on one side (Levin & Demers, 2020). One theory cannot suffice the aim of muscular rehabilitation and hence the lesson plan for the patient or clients will be based on both of these theories.
The clinical implication of the hierarchical theory is that the reflex analyses are based on the clinical assessment and requirement of the patients with neurological deficits. The work is based on the neural maturity and predictive functional capacity which is assessed at baseline (Cano-De-La-Cuerda et al., 2015). In stroke patients, the neurological recovery starts as soon as the episode is over and is brought under control and the side opposite to the affected side takes the functioning of the affected side to an extent which is dependent on the affected area (Sitaram et al., 2017). The limitation of this theory is that it does not explain the dominance of motor function related to the lowest level in the hierarchy.
The clinical implication of motor programming theory is that it places emphasis on the action patterns that are associated to the relearning in the situations that require a high level of motor control (Vaughan-Graham et al., 2019). The lesson plan, in this case, is related to the focusing on the key to recovery movements for obtaining the previously present functional capacity and is done in isolated muscles by retraining them and is also based on locating alternative effector muscles in case the high-level activity is not obtained (Cano-De-La-Cuerda et al., 2015). The limitation of this theory is that does not consider the reliance of the central nervous system on the musculoskeletal and environmental variables to achieve appropriate movement control. Activity oriented theory is another theory that can be considered but is refuted for the present proposal because it is focused on the achievement of complete functional recovery which in case of stroke patients is not possible (Cano-De-La-Cuerda et al., 2015).
The proposed methodology in the present proposal is an intervention with an aim to improve the voluntary functioning by using the hierarchical and motor programming theories of motor control. This done to achieve a full range of motions which is affected due to neurological deficit and the patient or client is not able to achieve complete motion.
The population in which stroke is generally seen are the people who are in the age group of older or geriatric. This is because the prevalence of cardiovascular diseases is more in the geriatric population and the comorbidities as the cerebrovascular accident are higher in the same. The participants selected will not be biased depending on the age, gender, race or culture. As the intervention or the lesson plan cannot be made generalized to a group of people but is dependent on the individual and the extent of the effect. The inclusion criteria will be: the study participants who have suffered a recent stroke, the range of motion and the affected region of the stroke is similar in the selected people so as to make sure that the baseline is same, participant selected will have only their upper extremity paralyzed. The exclusion criteria will be: if the paralysis is due to any other reason other than stroke, any other paralysis is seen along with that of the upper extremity, the participants who do not consent.
The issues that are seen in a patient with stroke is that they lose the motor and neurological functioning of the affected part in the present case it will be upper extremity. The healing or regaining of the neurological functioning is related to the affected part of the brain but the motor functioning is affected by the neurological activity. The skills that are affected and will be aimed to regain are motor functioning which can be divided into three parts that are joint movement, muscle tonicity, and muscle strength.
The lesson plan for the patient or client will be based on Fitts and Posner 3-stage model according to which there are three main stages of motor control learning. First is the cognitive stage, the patient is required to learn a new skill or in the present case, it is relearning existing skills. In this stage, the patient practices various tasks with the guidance and supervision of a trainer in which the patient makes mistakes and is able to learn from them to rectify them. The next is the associative stage where the tasks are performed with environmental restrictions. Here fewer errors are made and the patient understands the connection between the different components of skills. The last is the autonomous stage where the patient is able to perform the range of movement with proper motor control. The patient will be able to maintain automatisation and apply the skills learnt with ease in different practical real-life situations.
The lesson plan can be divided into five weeks where in the first week the patient's limb is trained for the stability, in the second week is concentrated on the degree of freedom and attain full range of motion by the joint, the third week will be for strength training of the limb, the fourth week is related to enhancing the tonicity of the muscle and the last week will be concentrating on the fine motor skills.
Prior to the commencement of the training, it is important the participants or patients or the clients understand they might be able to achieve complete motor control as they had before their stroke but at the same time, they should be encouraged to have complete faith so that they practice what they are taught. The first week will be related to the stability of the spine and the upper limb in relation to the upper body. Before the mobility of limb can be established it is required the stability is attained. Prior to any intervention or lesson, the upper limb will be assessed for the baseline measurement which will be done by the use wolf motor function test which is most commonly used tool which is valid for the assessment of upper extremity functional ability (Crum et al., 2019).
It consists of two strength measurement and a series of fifteen functional tasks and ranges from simple to complex movement and these tasks are timed. For the mobility of the joint will be the focus of the second week where the focus is on attaining a full range of joint movement where it will be started with simple shoulder ladder exercises where the patient will be asked to make movement on the wall as climbing of ladder with fingers and wheels using the shoulder joints (Muratori et al., 2013). This will be coupled with shoulder abduction and adduction with resistance (El-Nashar et al., 2019). At the start of the week, the patient will be assisted but by the end of the week, the patient should be able to do them without assistance. The full range of motions will be aimed to achieve which will be complete 180-degree adduction which is passive, passive assisted and active as per the capability of the patient (El-Nashar et al., 2019).
The third week is focused on the strengthening of the muscles of the shoulder, trunk and arms which are done by stretching and active resisted range of exercises like shrugging for upper trapezius muscles (El-Nashar et al., 2019). For the serratus anterior, the patient is asked to push against resistance with trunk and spine stable. The trunk control exercises are done active flexion and rotation. For strengthening of the arm muscles are done by weight lifting like dumbbell and barbell (El-Nashar et al., 2019).
The fourth week will be focused on increasing the tonicity of the muscle and this week will include the exercises from the previous week will be included along with which cat camel exercise on an exercise ball will be used. The final week will focus on the fine motor skills like holding of the pen, knife, etc. the patient will be taught to write a big letter using a marker on a sheet and gradually will be reduced in size prior to which the patient will be trained using finger gripper.
The assessment of the intervention or lesson plan will be in such a way that it will compare the progress to the baseline data and for the same pre-test and post-test will be conducted such that the comparison will show the improvement. The same test will be used pre and post the intervention. The other assessment which is valuable along with this and will be used is the assessment of the patient experience of the intervention and the motor control that is achieved by them. The most important thing that is to be taken care of is that the interventions should start as soon as possible to achieve maximum recovery.
Cano-De-La-Cuerda, R., Molero-Sánchez, A., Carratalá-Tejada, M., Alguacil-Diego, I. M., Molina-Rueda, F., Miangolarra-Page, J. C., & Torricelli, D. (2015). Theories and control models and motor learning: clinical applications in neurorehabilitation. Neurología (English Edition), 30(1), 32-41. https://doi.org/10.1016/j.nrleng.2011.12.012.
Coupland, A. P., Thapar, A., Qureshi, M. I., Jenkins, H., & Davies, A. H. (2017). The definition of stroke. Journal of the Royal Society of Medicine, 110(1), 9-12. https://doi.org/10.1177/0141076816680121.
Crum, E. O., Baltz, M. J., & Krause, D. A. (2019). The use of motor learning and neural plasticity in rehabilitation for ataxic hemiparesis: a case report. Physiotherapy Theory and Practice, 1-10. https://doi.org/10.1080/09593985.2019.1566941.
El-Nashar, H., ElWishy, A., Helmy, H., & El-Rwainy, R. (2019). Do core stability exercises improve upper limb function in chronic stroke patients?. The Egyptian Journal of Neurology, Psychiatry and Neurosurgery, 55(1), 38. https://doi.org/10.1186/s41983-019-0087-6.
Fridland, E. (2017). Skill and motor control: intelligence all the way down. Philosophical Studies, 174(6), 1539-1560. https://doi.org/10.1007/s11098-016-0771-7.
Hatem, S. M., Saussez, G., Della Faille, M., Prist, V., Zhang, X., Dispa, D., & Bleyenheuft, Y. (2016). Rehabilitation of motor function after stroke: A multiple systematic review focused on techniques to stimulate upper extremity recovery. Frontiers in Human Neuroscience, 10, 442. https://doi.org/10.3389/fnhum.2016.00442.
Levin, M. F., & Demers, M. (2020). Motor learning in neurological rehabilitation. Disability and Rehabilitation, 1-9. https://doi.org/10.1080/09638288.2020.1752317..
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Muratori, L. M., Lamberg, E. M., Quinn, L., & Duff, S. V. (2013). Applying principles of motor learning and control to upper extremity rehabilitation. Journal of Hand Therapy, 26(2), 94-103. https://doi.org/10.1016/j.jht.2012.12.007.
Sitaram, R., Ros, T., Stoeckel, L., Haller, S., Scharnowski, F., Lewis-Peacock, J., ... & Birbaumer, N. (2017). Closed-loop brain training: the science of neurofeedback. Nature Reviews Neuroscience, 18(2), 86. https://doi.org/10.1038/nrn.2016.164
Vaughan-Graham, J., Patterson, K., Zabjek, K., & Cott, C. A. (2019). Important Movement Concepts: Clinical Versus Neuroscience Perspectives. Motor Control, 23(3), 273-293. https://doi.org/10.1123/mc.2017-0085.
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