The Use of Meaningful Activity in Neurological Rehabilitation

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The Use of Meaningful Activity in Neurological
Rehabilitation

• An Occupational Therapy
• Approach to Motor Control and Motor Learning

Heiko Lorenzen, Bc. of Health in OT Döpfer School
for Occupational Therapy Cologne, Germany
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Overview

• Introduction to Occupational Therapy
• Introduction to CIMT
• Application of CIMT in Occupational Therapy
• Case Example Musician
• Discussion

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Basic Assumptions in Occupational Therapy

• Occupation refers to all meaningful activities
  that make up an individual life
• The engagement in occupations is associated with
  participation, health, well-being and quality of
  life
• Occupational therapists aim to engage their
  patients in activities that are meaningful to
  them in order to facilitate participation

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Occupational Therapy in Motor Control and Motor
Learning

• Motor control is the ability to fixate the body
  and to move the body (Gilmore Spaulding 2001)
• Motor learning refers to changes in movement
  behavior as a result of practice or experience
  (Gilmore Spaulding 2001)
• Occupational therapists make use of three
  different interventions in motor learning (AOTA
  2008)
• Preparatory methods
• Use of purposeful (therapeutic) activities
• Engagement in desired occupations

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Introduction to the Constraint Induced Movement
Therapy (CIMT)

• CIMT is based on the learned disuse after the
  onset of neurological disorder

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Development of learned disuse
(figure adapted from brainworksrehab.com)
Injury / Stroke
Unsuccessful motor attempts
Feelings of failure
Behavior suppressed
Learned disuse of limb
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Introduction to CIMT

• The downward spiral of disuse leads to greater
  disability of the affected arm and hand (Wolf et
  al 2006)
• Use it or lose it!
• Affected limb needs to be forced into activity
• Typical CIMT program 3 hours/day of therapy, 5
  days/week for 4 weeks 5 6 hours at home
  (Earley et al 2010)

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Introduction to CIMT

• Criteria for application of the CIMT method (Wolf
  et al 2006)
• 6 months post-stroke
• No or mild cognitive impairments (MMSE 24)
• Ambulatory without the use of assistive devices
• 45 shoulder flexion and abduction
• 45 external rotation at the shoulder
• Full elbow extension
• 45 forearm supination and pronation
• 5 wrist extension
• 5 digital exension (specifically thumb, index
  middle finger)
• Ability to grasp and release a washcloth 3 times
  within 1 min.

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Application of CIMT in Occupational Therapy

• Application of preparatory methods
• stretching of the affected upper extremity
• joint mobilization
• training the strength of the hand
• taktile stimulation

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Application of CIMT in Occupational Therapy

• Use of purposeful (therapeutic) activities
• practicing to unscrew a bottle of water
• practicing to use cutlery
• practicing to grasp and move a table tennis
  racket
• practicing the typical movements for playing a
  certain musical instrument
• practicing to use a jig saw

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Application of CIMT in Occupational Therapy
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Application of CIMT in Occupational Therapy

• Performance of meaningful activities (ideally
  within the own context)
• using cutlery at home or in a restaurant
• playing table tennis with a friend or in a club
• playing the musical instrument
• doing craftswork at home or at work

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Case Example Musicianfrom Earley et al (2010)

• 52 year old woman, 4 years after left-hemispheric
  stroke
• Decreased gait functions
• Decreased strength and decreased use of the
  affected right upper extremity
• Difficultuies in performing several basic ADLs

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Case Example Musician

• Preparatory methods
• Manual stretching of anatomic structures
• Progressive resistive exercises
• Weight bearing and joint compression
• Performance of purposeful activities
• Simulation of violin playing
• Engagement in cooking activities
• Arranging a photo album

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Case Example Musician

• Engagement in a variety of meaningful activities
  at home during 5 6 hours daily
• After functional improvements and increased
  self-confidence this included also practicing to
  play her violin

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Case Example Musician

• Some of the results
• 50 increase of grip strength and pinch strengh
• Improvement of fine motor hand use measured with
  the Nine-Hole-Peg Test (intake score 28 s /
  discharge score 21 s)
• 4 years after the stroke and 1 month after the
  CIMT intervention the musician returned to her
  role of playing the violin in a community
  symphony orchestra

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Literature

• American Occupational Therapy Association (AOTA)
  (2008) Occupational Therapy Practice Framework
  Domain and Process (2nd ed.). American Journal of
  Occupational Therapy, 62, 625-683
• Earley D, Herlache E, Skelton DR (2010) Use of
  occupations and activities in a modified
  constraint-induced movement therapy program a
  musicians triumph over chronic hemiparesis from
  stroke. American Journal of Occupational Therapy,
  64, 735-744
• Gilmore PE, Spaulding SJ (2001) Motor control and
  motor learning implications for treatment of
  individuals post stroke. Physical Occupational
  Therapy in Geriatrics, 20(1), 1-15
• Townsend E, Polatajko H eds.(2007) Enabling
  occupation II advancing an occupational therapy
  vision for health, well-being and justice through
  occupation. Ottawa CAOT
• Wolf SL, Winstein CJ, Miller JP, Taub E, Uswatte
  G, Morris D et al. (2006) Effect of
  constraint-induced movement therapy on upper
  extremity functions 3 to 9 months after stroke.
  JAMA, 296, 2095-2104

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Thank you for your attention!

• Heiko Lorenzen
• Referent and Lecturer for Occupational Therapy
• Referent for ICF in Neurological Rehabilitation
• Referent for Fatigue Management
• Contact heiko.lorenzen_at_web.de