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The Neuro Power Hour, Episode 1: Movement
68 Plays3 months ago
In this episode, Dr. Michael Powers discusses movement, from development of movement through the evolution of motor control theories. He highlights how Dynamic Systems Theory reflects our best current understanding of movement, and how this theory can be incorporated into physical therapy clinical practice by considering how movement is shaped by the interaction between the individual, the task, and the environment.
All music courtesy of Free Music Archive and used via attribution 4.0 international license.
Intro and Outro: Stylin' by JMHBM
Transitional: Our Reality by Ketsa
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Transcript
Introduction to NeuroPowerHour
00:00:09
Speaker
Welcome to the NeuroPowerHour. your host and neurological navigator, Dr. Michael Powers, physical therapist, board certified in neurologic physical therapy and clinical electrophysiology.
00:00:22
Speaker
Let's get started.
Core Focus: Movement in Physical Therapy
00:00:23
Speaker
On today's episode, we're going to be talking about movement. And this is a big topic, obviously, but it's the bulk of our professional identity as physical therapists. So we really want to, when we're talking about movement,
00:00:38
Speaker
We want to start at the ground level and think about how do we even as humans develop movement? How do we control movement? In courses I teach, I'll talk at length about motor control theories. Students will also learn about development of movement from birth throughout the lifespan.
00:00:58
Speaker
And I'm not a pediatric physical therapist. However, I do think even if you're not going into peds, it's imperative to have an understanding of how movement develops. So that was a little bit of table
The Movement System Explained
00:01:10
Speaker
setting. talked about quite a bit there in the intro. Let's break it down and start by looking at what we mean when we're talking about the movement system.
00:01:20
Speaker
So the movement system is a way to conceptualize or think about how humans go about moving. And this is the integration of all the different body systems that generate and maintain movement at all levels of bodily function.
00:01:38
Speaker
Within PT school, within healthcare, we think about different systems. So maybe we have the cardiovascular system, we have the nervous system, we have the musculoskeletal system. And typically we learn about these systems in silos or we learn about um key functions or key components of these various systems.
00:01:58
Speaker
As physical therapists, however, what we really want to emphasize or think about as we're learning all these different systems is how these systems interact in terms of the overall movement system. So thinking that human movement is a complex behavior within a specific context. So
Context-Specific Human Movement
00:02:18
Speaker
movement is not as simple as I'm bending my elbow.
00:02:22
Speaker
It might be the context of I'm sitting at a coffee shop talking with a friend, and I'm bending my elbow while bringing a coffee cup or a coffee mug up to my mouth. So something that seems from the outside possibly very simple is requiring a lot of demands across multiple body systems. And again, it's context specific. We'll be coming back to that Throughout different presentations and different podcasts, the real importance of the environment and movement being context specific and really driven not by just a movement, but thinking of movement as a goal directed, personally relevant activity, we're trying to accomplish something.
00:03:13
Speaker
to For physical therapists, we are capable and competent and experts, I should say, let me expand the terminology here, at working with individuals and clients across the lifespan.
Age-Related Movement Changes
00:03:27
Speaker
And the big reason we can do that is because of this emphasis on the movement system. So we can take a look at how movement, expected movement, what we expect to find, how babies move all the way through the geriatric population.
00:03:44
Speaker
Having a key understanding of the various systems involved in movement is going to be key. So for instance, in courses I teach, we may talk about expected age-related changes with movement. We'll talk about changes in the vestibular system, changes in the somatosensory system, changes with vision that occur with age.
00:04:07
Speaker
As we learn about these processes, we see how movement may change across the lifespan. However, the underlying premise that movement is context specific, it's personal, it's what's relevant to the person.
00:04:22
Speaker
lets us know that any of these expected systems that are impacting the movement system, so vestibular, maybe vision, somatosensory, doesn't tell you exactly how movement's going to look in an individual. It gives you an idea of what may happen, but we drill deeper into that context, that specificity of what's happening in the environment.
00:04:45
Speaker
So um again, movement is going to be the key aspect of physical therapy, professional identity.
Reflex Theory and Its Limitations
00:04:52
Speaker
So let's drill down a little bit and talk about how movement is developed, how people thought about motor control in the early stages, and where we've kind of landed for best current evidence in terms of motor control.
00:05:10
Speaker
So back in the day, feels like we're going old school here, back in the day, but really starting out in terms of explaining movement, there was the concept of what's called reflex theory. And this was proposed by Charles Sherrington, early nineteen hundreds And I want to take a moment here as we're going through some historical motor control theories to keep in mind that people develop these theories based on observations, testing hypotheses. So just because now maybe we feel these theories don't represent what we know, i don't want us to be disparaging of people that did the work beforehand because we're constantly building on what others have done. that phrase standing on the shoulder of giants. So we might get a fake sense or a false sense of um superiority because we know more now than what was known historically. But I'd like us to keep in mind, maybe what we know today will be disproven down the road. So a little humility as we move through talking about these theories is warranted.
00:06:19
Speaker
So let's go back to reflex theory. The key premise of this theory is that movements and behaviors are the result of individual reflexes chained together. So here we see in reflexes, we can see them if we talk about deep tendon reflexes. You tap the tendon with the reflex hammer. You get a sensory impulse that moves centrally, synapses in the spinal cord. You get a motor output, and you get a little bit of a twitch.
00:06:48
Speaker
If we think about developmentally or we think about maybe babies, maybe babies, we think about babies, um early stages of life. There's also what are called primitive reflexes. um movements and behaviors that are considered somewhat obligatory that then get what's called integrated or that then resolve over time. So we've got our deep tendon reflexes, we've got our primitive reflexes, and essentially what we observe is with a given stimulus, we get a so expected or a stereotypical response. Now, that will explain movement in some cases, right? If we smack someone, smack, if we tap someone with our reflex hammer, we get an output. We see babies. I'm a fan of the AT&R, the asymmetric tonic neck reflex, that little fencing position. So we notice that the one extremity extends, the other one flexes.
00:07:45
Speaker
And that can explain movement, however, in very limited circumstances, right? It doesn't explain spontaneous movement. We now know that people are capable of moving very much independently of um inputs happening. We can create a movement without a sensory input,
00:08:07
Speaker
It doesn't explain um fast movements either, those that occur without any sensory input. So essentially, most of the limitations of reflex theory can be distilled down to it doesn't explain any movement that happens without some form of sensory input.
00:08:24
Speaker
It also doesn't explain how movement changes depending on context. Remember, I previously mentioned how important it is to consider the environment and the movement context because we will change our movement to meet the demands of the situation and the environment. So reflex theory is pretty limited here.
00:08:43
Speaker
However, because reflex theory does explain in some circumstances certain stereotypical movements, there are cases to be made where it might explain some movement, and if we think about the historical pattern of treatment within physical therapy, these reflex considerations are a lot of the underlying premise behind proprioceptive neuromuscular facilitation, also known as PNF. So PNF is a type of handling, type of exercise, intervention. You're really tapping into
00:09:23
Speaker
synergistic movement patterns, so movements along muscles that are supposed to coordinate or work together. But there's a lot of handling there that can include trying to what's called facilitate or increase motor output and inhibit or decrease motor output, a lot of it tapping into these reflex responses.
00:09:47
Speaker
I'm not going to go into in this presentation the current state of neural world in terms of PNF being evidence-based or not. and There's a whole big discussion about PNF and NDT.
00:10:02
Speaker
We're not going to go into that here. I'm
Hierarchical Theory of Movement
00:10:04
Speaker
merely setting the stage of reflex theory and some things that are observed. linked together to guide treatment. So a take-home message here for all of you as well is that theories are pretty important in terms of driving practice patterns. These theories really are about describing large sets of observations and trying to make predictions about the future.
00:10:29
Speaker
And what I think we want to keep in mind is early on within motor control theories as it relates to physical therapy practice, we probably leaned more into a pathophysiology or maybe just a physiology model where we were thinking stimulus and response and really not thinking about The movement system. So maybe the early motor control theories were heavily leaning into the nervous system, maybe a bit of the musculoskeletal system, but not really considering context environment, the reality of what we see. Humans are complicated. We're not just input in and put out. We have a brain that is operating on many different levels all the time. And so this early reflex theory does not explain everything about movement. But it may accurately...
00:11:26
Speaker
give us some recommendations or suggestions on possible ways to initiate treatments some of the time. Let me stop there. I don't want to go deep into the treatment area because we want to focus on the motor control theories, but that's ah the background on the reflex theory.
00:11:44
Speaker
Now I mentioned we have brains and our brains are operating all the time. And so after reflex theory, or not after, it's not necessarily sequential, but ah another theory that evolved was hierarchical theory. And this really looked at the brain and essentially the central nervous system as the boss. So if we think about an organizational structure map, we think about who's at the top of the organizational chart, you would essentially have the brain and spinal cord injury at the top. giving out orders to lower centers. So in this model, the hierarchical theory, it's a top-down structure. So brain and spinal cord are in charge of the movement. And at first glance, that really makes a lot of sense. And it does explain a good amount of what we may see clinically.
00:12:33
Speaker
One key consideration from this model that I think holds up is that the cortex is Typically in adults who are neurologically intact, the cortex, so I'll just say brain cortex, is typically inhibiting or calming down the lower centers. What I mean by that is in an intact central nervous system, we do not see some of the findings that we would see later on with an injury
00:13:09
Speaker
that are considered part of the upper motor neuron syndrome. So let me rephrase this. Let's say someone has had a traumatic brain injury or a stroke, cerebrovascular accident that affects the corticospinal tract.
00:13:26
Speaker
If you don't know what corticospinal tract is, that's fine. Put it to the side. But let's say someone's had a brain injury. If the part of the nervous system is affected that typically inhibits the lower centers, we've got now a nervous system that's ramped up. And I'm using very global statements here. So brain injury, um stroke, instead of my reflexes being normal, my deep tendon reflexes being normal, Instead of my muscle tone being normal, and I use normal in air quotes, don't always love that term, but let's bear with it for now.
00:13:59
Speaker
And these primitive reflexes, these reflexes that we saw in early age as as babies that were then integrated, those should not be present anymore.
00:14:12
Speaker
under normal conditions. I have a brain injury, everything goes up. And I had a neurologist speak to our class and when I was in PT school, and I thought he gave the most succinct, easy to remember explanation.
00:14:27
Speaker
Upper motor neuron injury, everything goes up. So we have up in terms of deep tendon reflexes, so hyperreflexia.
00:14:38
Speaker
We have increases in tone, hypertonicity, and we have up or the presence or positive of these primitive reflexes. So think about if you've learned how to do a Hoffman's reflex or a Babinski reflex, those are those primitive reflexes should not be present in normal, um in intact central nervous system in adults, those are going to be present with central nervous system dysfunction, the upper motor neuron syndrome. So these damage to the cortex, higher centers, upper motor neuron, we're going to have up findings, up reflexes, up in tone, and up in primitive reflexes.
00:15:25
Speaker
So the hierarchical theory does explain to a certain extent what we actually see clinically. There are some limitations of this theory, though. This assumes all lower level behaviors and movements are primitive and non-adaptive, which is not actually the case. And it doesn't account for bottom-up control. We'll learn later. I'm kind of um I guess, setting the stage or letting you know down the road, we're going to talk about dynamic systems theory and that everything is much more running in parallel or simultaneously as opposed to top down. So hierarchical theory does explain some things, but it doesn't explain everything.
00:16:08
Speaker
And hierarchical theory tends to be the basis for NDT. um Again, I'm not going to go into huge detail about treatments, but I did want to mention that this hierarchical theory supported or was the causative, I guess, um theory for NDT, which was the thinking here was the key is proper movement and handling and restriction of abnormal movement. So here the goal was we don't want any abnormal movements. We want correct movement. And it was very much gated in terms of you didn't progress from one movement to the next until you had good quality movement. at kind of the lower level, either activity, skill or position. So it was a hierarchical theory with top down control.
00:16:59
Speaker
Not that I'm saying there's not a time and place for NDT, although that's heavily debated, um very controversial and lot of current research indicates that NDT does not provide good outcomes in across a variety of conditions, situations, and that may be because it's very much reliant on it's very much therapist or clinician-driven. It's about the therapist handling in the certain spots, and it's about perfect movement, whereas more current research is suggesting it's about intensity of practice, goal-oriented behavior, in the person learning from mistakes.
00:17:41
Speaker
There's a lot of people clinically that are proponents of NDT. It's, again, highly debated in the neuro world. Currently, my best understanding is the research does not support it. um Absence of evidence doesn't mean evidence of absence. However, when set up in well-controlled studies, NDT, the evidence is not in favor of NDT at this time.
00:18:06
Speaker
So we'll leave it there. I don't want to get into a big controversy about and NDT and have having people coming at me here. Let's move on to motor programming theory.
00:18:17
Speaker
So this theory has some evidence in some
Central Motor Programs and Ecological Theory
00:18:21
Speaker
situations. This is the thought that there's a motor program or a plan for movement within the central nervous system. So a couple of things I think about motor programming theory, um and this this may or may not be 100% accurate, but I think about motor programming. If you've learned to sign your name, that's a motor program. You can't really slow down. and not do it that way, um you've got a motor program or a way of doing it.
00:18:47
Speaker
There's thoughts about what's known as a central pattern generator. So the spinal cord, there's evidence that the spinal cord has the capacity to learn. And there were a series of studies um Kind of, mean I think we got some good evidence from it. I don't love the way the study was done, but they essentially um produced spinal cord injuries in cats. But they were able to get the cats back walking again, despite there not being a communication from the brain.
00:19:16
Speaker
through the injured spinal cord area, but they essentially were able to tap into, um, the spinal cord showed evidence of learning via some stretch reflexes, via some other sensory inputs, and they were able to get the cats walking again.
00:19:32
Speaker
Limitations of the motor programming theory, um it mostly focuses on the central nervous system, so it's not an all-encompassing theory, and that the central motor program is not the only determinant of action. So it doesn't really consider fatigue, environment, or other personal factors.
00:19:52
Speaker
final one i want to touch on before we get to dynamic systems theory is ecological theory and this one really is was all about the environment so it considers interaction between the person and the environment with the thought that perception is vital to goal directed behavior so perception noticing what's happening and thinking about what we want to do drives movement so here um recalling the example of me sitting in a coffee shop, talking to a friend. I perceive the coffee cup in front of me. I perceive that either I'm thirsty and or tired. And then I'm going to move. I notice where the cup is. I'm going to move, bring the cup up and and have a sip.
00:20:35
Speaker
Limitation of the ecological theories. There's less emphasis on the role of the nervous system in movement. So it it adds in the environment, but doesn't add in the nervous system.
00:20:46
Speaker
So we've talked up to this point about multiple different motor control theories. We've talked about reflex theory. chaining reflexes together doesn't really tell us, though, how movement is produced with the lack of sensory input.
00:21:03
Speaker
We talked about hierarchical theory, kind of a top-down model. This doesn't really tell us, though, what happens for bottom-up movement, and it makes an assumption that lower-level behaviors and movements are primitive and non-adaptive, and from a treatment perspective, it really overly emphasized perfect movement and needing to move well at one at a lower level of function or task before progressing.
00:21:32
Speaker
We talked about motor programming theory, the idea that there could be motor programs, but it doesn't really consider fatigue or the environment. And then we talked about ecological theory, and that does look at the environment, but doesn't really incorporate the nervous system.
00:21:52
Speaker
So we have all those. We've set the stage here.
Dynamic Systems Theory
00:21:55
Speaker
And let's move on then to dynamic systems theory, which is really where we land in terms of best current evidence.
00:22:07
Speaker
Dynamic systems theory was developed in the early to mid 1900s. And what we're going to do here is we're going to think about or conceptualize the body as a mechanical system subjected to internal and external forces. So those of you that love physics, you're going to be super happy. Those of you that maybe didn't like physics so much, sorry, buckle up. Gotta have your physics in here. So the body is a mechanical system and there's internal and external forces. So I like this idea. So we've got the the body as this system and the body is going to create some forces, but the body is going to respond to some forces.
00:22:50
Speaker
A very key concept here, one that'll keep coming up, and it's really, i think about this concept all the time during treatments, is the concept of degrees of freedom. So what are all the possible movements that can be occurring across multiple joints?
00:23:09
Speaker
So let's consider maybe someone in standing, someone who's trying to maintain their balance, so trying to manage their center of mass over their base of support.
00:23:21
Speaker
Now in standing, that individual is having to control possible movement across the ankle, and the knee the hip some some ways across the trunk, or you know if you want to pull that in there. And let's say maybe they're doing a reaching task. So now they're also controlling movement across the shoulder, elbow, hand. And if they're turning to look, there's degrees of freedom across the head and neck as well.
00:23:50
Speaker
The reason I feel that degrees of freedom is such an important concept is if we think about someone maybe who has weakness in an area or has maybe they have ataxio difficulty controlling their movement across multiple joints,
00:24:06
Speaker
the concept of controlling for degrees of freedom becomes very important, or the concept that people are trying to solve for a degrees of freedom problem will become relevant in clinical practice. So right off the bat, if you start thinking about movement,
00:24:25
Speaker
And wondering about, well, what are the degrees of freedom for this specific task that the person is trying to do? Remember, movement is a goal-oriented behavior. It's context-specific. So if we think about, let's go back to the example, I'm sitting down in a coffee shop and I'm reaching for a cup of coffee.
00:24:44
Speaker
I'm supported in a chair. I've removed a lot of degrees of freedom for this movement, right? I'm sitting down. I don't really have to control my lower extremities.
00:24:55
Speaker
Let's assume I'm sitting with decent posture, which is unlikely. I tend to slouch, but let's assume I'm sitting. My back is well supported. So degrees of freedom for this movement would be what's happening on my right arm. I'm very right hand dominant, so it's going to be my right hand reaching for the coffee cup. So I've got some movement that's going to be occurring at my shoulder, elbow, hand, probably my head as well.
00:25:17
Speaker
Contrast that with I'm in standing, reaching for the coffee coffee cup. I've got degrees of freedom now across my lower extremities and everything else in my right upper extremity, head and neck.
00:25:30
Speaker
So degrees of freedom is something that I would encourage you to keep thinking about and coming back to because this can really be very beneficial, not only in assessing movement, but in planning movement and thinking about treatment down the road.
00:25:47
Speaker
Another key consideration of dynamic systems theory is the concept of synergies. Now later, you'll learn about abnormal synergies as it relates to maybe traumatic brain injury and or stroke when muscles start working together internally.
00:26:03
Speaker
in a way that doesn't allow for smooth movement. But as it relates to dynamic systems theory, we're going to talk about synergies as muscles working together as a unit. So there's certain functional movements where some muscles need to be turned on, some are turned off, but it's typically not as straightforward as all the flexors in the upper extremity or kicking on at the same time. Instead, what you'll probably have is a very smooth, graded amount of muscle contraction and relaxation along groups of muscles to get a functional task completed.
00:26:42
Speaker
Dynamic systems theory is a broad, complex theory with few limitations. A key consideration here is the body, as it's solving a movement problem or the individual, let's say, is self-organizing. There's really no need for higher control.
00:27:00
Speaker
And later when we'll talk about motor learning, so right now we're talking about motor control, but when we later talk about motor learning, so learning a new task or relearning a task after a neurologic injury, we learn that The less kind of higher control we need or the less we need to actively think about emotion, the better it becomes. And dynamic systems theory is consistent with that, that we don't want a micromanaging CEO. We don't want a hierarchical control. We want movement distributed across the individual so that it's smooth.
00:27:38
Speaker
A key one thing that we'll circle here and we'll talk a little bit about this in this presentation or in this. um Yeah, in this presentation and we'll keep coming back to this is the movement problem or how someone is deciding to move.
00:27:54
Speaker
is really happens at the interaction of the task so what am i trying to accomplish the individual what is my strength what is my sensation what is my motivation what is my cognition and the environment is the environment noisy is it relaxed is it well lit so the movement is not just i'm picking up the coffee cup movement is okay i'm picking up the coffee cup while I am around some people. So maybe, maybe I'm a very nervous person. And I've met i'm I'm meeting a friend for the first time. And so my task is to not only take a sip of coffee, but I don't want to burn my tongue. I don't want to spill all over myself. um Individual level is my I'm strong enough to pick it up. Maybe my hand's a little jittery from either nerves or maybe I've had too much coffee. The environment, it's very loud, but it's well lit. These can all impact how my movement is happening.
00:29:00
Speaker
Let's go back real briefly to degrees of freedom. So I want to really drive this point home. Degrees of freedom is the sum of independent dimensions of movement. So all potential motion throughout the joints of the body.
00:29:14
Speaker
An example I'll frequently give is when I learned how to snowboard many years ago. And you'll see this across learners in general when you learn a new skill. You're very stiff and rigid. And that's because as a new learner, you're trying to solve for the degrees of freedom problem. So you put someone on a snowboard.
00:29:32
Speaker
Their ankles are going to be pretty secure in the in the boots, but what you're going to see is a lot of stiffness. The hips and knees are going to be very stiff. The arms probably out of the side in the high guard position.
00:29:45
Speaker
um You can think about any new task that someone's starting. You just see a lot of what's called co-contraction. You see a lot of stiffness, and that is a learner trying to control for degrees of freedom. and you've got a lot of co-contraction, you don't see a lot of smooth synergies.
00:30:01
Speaker
But as someone improves at learning a new movement or developing a skill, these synergies develop further. These synergies are dynamic and flexible. And one example that I've i've thought about is think about Maybe you're doing a pull-up exercise. In this case, your biceps are working in synergy with your lats for the pull-up. um I'm thinking of a pronated grip here, right? So your biceps and probably brachialis, maybe some additional, obviously, flexor muscles in the in the wrist are kicking in. But biceps are working in synergy with lats. But if you think about when you're eating, your biceps have to work more in synergy with your pecs and deltoids. So synergies are going to be teams that develop, that are dynamic and flexible depending upon what the task is that we're trying to accomplish so let's put a bow on dynamic systems theory so we're taking in some ways the not i don't want to say the best but we're taking concepts from prior motor control theories we've discussed and this theory is the one that's best borne out by the evidence this one is the one that we find in clinical practice if we think about
00:31:18
Speaker
motor control, if we have an understanding a dynamic systems theory, this is going to help lead us to the best
Task-Oriented Approach to Movement
00:31:25
Speaker
outcomes. So recalling our key considerations here, the body is a mechanical system.
00:31:31
Speaker
It's subjected to internal and external forces. So I can produce forces in my body, but I'm also responding to forces coming in into me.
00:31:42
Speaker
I am constantly solving for degrees of freedom. So all the possible movements across all the joints, if I'm up and moving around, my degrees of freedom are much bigger. is It's a much larger sum than if I'm sitting down. This will kick in later as you start to think about treatment progressions and regressions, because you can think about, well, how many degrees of freedom are there? Did I want to make the activity harder for someone? Let's release some degrees of freedom. Do I want to make it easier? I'm going to decrease or constrain some of those degrees of freedom.
00:32:18
Speaker
Synergy, so thinking beyond, um this is a pet peeve of mine when we think about exercise prescription in the neural world, we're not doing single direction sets of 10. So we're not having someone doing three sets of 10 of short arc quads.
00:32:33
Speaker
That doesn't pull in synergies. That's not goal-oriented. It's not high intensity. So thinking about synergies, getting muscle groups working together for a functional task is going to improve your treatment prescription and your overall outcomes.
00:32:50
Speaker
And finally, we talked about movement ah the The patient or the individual is solving a movement problem, and that exists at the intersection of the task, the individual, and the environment. So we're going to close this presentation or this topic today by talking about what's called the task-oriented approach, this consideration of the individual, the task, and the environment. This is consistent with best current evidence, and this will really set the stage for how you'll look at
00:33:24
Speaker
analyzing movement or analyzing how someone is approaching movement, and then eventually how you're going to set up your treatment interventions because you've considered the individual, the task, and the environment.
00:33:39
Speaker
So the task-oriented approach, why what's so important about this approach? This approach, again, places movement at the intersection of the individual, the task, and the environment, and it's consistent with dynamic systems theory. So again, what I'm telling you here is that dynamic systems theory, task-oriented approach, are most consistent with our best current evidence. That's why we're spending so much time here.
00:34:05
Speaker
The task-oriented approach is a problem-solving approach that emphasizes practice. there's no There's no silver bullet. There's no way around. You have to practice. We learn from our mistakes. And here's another key consideration that I think is challenging for students and novice clinicians to fully appreciate.
00:34:28
Speaker
We have to, and I hate to use even the word allow because it it sounds like we're in control of someone, but we have to allow opportunities for mistakes. Nothing is going to be as powerful in learning as learning from mistakes. Now, obviously, we want these to be within relatively safe environments, and we don't want someone making mistakes repeatedly to the extent that maybe they are losing motivation.
00:34:57
Speaker
However, if we structure movement in such a way that the person is never making mistakes, they're not going to learn as deeply and powerfully. And let's take a pause here and think about some metacognition or thinking about your own learning. It's okay to make mistakes.
00:35:14
Speaker
Again, safe mistakes. We don't want to be dropping all the patients we're working with, or we don't want to be getting really poor grades on all our exams. However, if you really reflect and think about times you've made mistakes, you tend to recall those mistakes, and you most likely have not made the same mistake multiple times. So you've done some powerful learning. And I think that's key to remember as a learner,
00:35:41
Speaker
But I think it's key to remember for your patients as well. And so number one, really believing in the power of learning from your mistakes is critical because then number two, you can communicate that to your patients, be empathetic when they're frustrated, but you really will be approaching your treatments with the best current evidence.
00:36:06
Speaker
And finally, the task-oriented approach is Key here is what's called salience. This is the word I love to overuse. You'll have different instructors and people in your life that have yeah pet words or keywords they use. I love talking about salience. So salience is, is it important to the person?
00:36:23
Speaker
So as you're working with a patient, um, really finding out what's important to them, what they like doing. So if I have someone that previously was maybe they enjoyed fishing, let's say, let's say I've got an elderly gentleman I'm working with. He enjoyed fishing. He's had a stroke. He has difficulty using his right arm.
00:36:46
Speaker
Do you think it's going to be better or more impactful to him if I have him reaching for cones? or if I have him using a simulated or real fishing rod to cast.
00:37:00
Speaker
Think about that, right? And I can do both activities. If we think go back to thinking about degrees of freedom, I could do these in sitting. If I wanted to make it harder, I could do it in standing. But it's going to be much more salient if he can see that the activity we're working on is giving him the the upper extremity practice, which is what I want as a therapist. But it's giving him something salient that he wants to do, which is get back to fishing. So task-oriented approach, we're going to rely on a lot of practice, learning from mistakes, and salience.
00:37:34
Speaker
As we think about practice, the evidence strongly strongly, strongly, strongly, strongly indicates that it's that high intensity and repetition of salient tasks is what's needed. And here I'm talking about the adult population. I'm i'm leaning into adults with neurologic injuries, primarily the central nervous system.
00:37:56
Speaker
High intensity, high repetition of salient tasks gives us the best opportunity for both neuroplasticity, so some creating of new synapses, some learning within the nervous system, and functional gains.
00:38:12
Speaker
And in contrast to the hierarchical model of motor control and what I've presented previously about NDT treatment, the goal is not perfect movement. The goal is solving the movement problem.
00:38:27
Speaker
Here I make the example that's maybe not the most politically correct, but I think it's easy to it sticks in your head. i enjoy running. I've run multiple various distances of races and I'm i'm reasonable, not the the fastest, not the slowest, but I'm always struck by when I'm. running and I think I'm doing well and I see someone in front of me that is huffing and puffing and maybe they are leaned completely to the side and they're all for lack of a better term akimbo just what looks to be terrible running form and they're pulling away from me so they are solving their movement goal
00:39:04
Speaker
while not moving perfectly. And we could argue and have debates about, well, what's the long-term outcome on joints or what's um you know what is the long-term effects in certain areas if we don't have perfect movement.
00:39:17
Speaker
However, the our best current evidence in with how we currently provide services within physical therapy, we're not if we focus on perfect movement, we're losing functional gains and we're losing neuroplasticity. So maybe long-term, I'd make the argument, trying to get the movement cleaner to think about potential joint risks, et cetera. um And again, there's some wiggle room you'd have to consider how bad does the movement look and making sure the person is safe. But historically, we have made the mistake as a profession of overemphasizing normal movement, and we've left functional gains and neuroplasticity on the table. So I strongly encourage you...
00:40:01
Speaker
not to go that route. Now, I'm not saying let someone, you know, that we're not going to ignore movement quality, but that's going to be in the background and the high reps, learning from mistakes, salient practice is going to be in the foreground.
00:40:17
Speaker
And that's just a little bit different than maybe what's been done historically.
Conclusion and Modern PT Theories Recap
00:40:22
Speaker
Briefly want to touch on what we mean in these individual or in these buckets in terms of the individual, the task and the environment.
00:40:29
Speaker
So when we say movements at the intersection of the individual task and the environment, we can look at what's happening in each of these almost like a recipe for cooking where then as the treating clinician, we can adjust some of these variables or the way some of these variables present will inform how we're going to come in with treatment. So the individual level, I think, is pretty straightforward. These are a lot of things that we may be assessing during our examination and our evaluation. So what is the individual bringing to movement?
00:41:03
Speaker
We can very succinctly break these down into three categories. So at the individual level of movement, I want you to think about Okay, what is the motor and action function the person's doing? So this could be strength. This could be coordination. This could be flexibility. What is the capacity to to have motor and action function? So again, that's going to be assessed during your examination evaluation.
00:41:32
Speaker
What is the sensory perceptual function? So this might be looking at somatic sensation, proprioception, checking for do they have a unilateral neglect? What is their ability to take in information?
00:41:46
Speaker
That's the sensory perceptual function. What is their ability to produce a movement? That's their motor action function. Then we'll layer on cognitive function. What is their overall motivation? What is their cognitive status? We'll learn later about if someone has cognitive decline or is engaged in tasks that require a lot of cognitive resources, we may see decrement in their movement performance.
00:42:12
Speaker
So again, at the individual level, think about Can the person take in information? What's their sensory perceptual function? Can they produce an output? What's their motor action function? And then can they make sense of it all? What's their cognitive function? So that's at the individual level.
00:42:29
Speaker
For the task, there's a lot of different ways we can analyze the task that that a person is doing. So let's take sit to stand. That would be a task. Or let's take um walking. That would be considered a task.
00:42:42
Speaker
We can analyze that task in order to determine how best to then approach treatment. So a lot of times students get stuck on in the weeds of the task analysis or categorizing the task. We'll talk more about that in future presentations.
00:42:59
Speaker
But here I'm just going to lay a general overarching. Here's some things that you could look at. And the goal here, again, is to you categorize it so you figure out well, how can I go about structuring my treatment? What's most indicated in terms of a practice schedule, making it easier or making it harder?
00:43:19
Speaker
Some task considerations include, is the task discrete? Does it happen and it's over, like flicking a light switch? Is it continuous, where it's ongoing and the start and the stop is arbitrarily determined by the mover? That would be like walking. Or is it serial, where it's a series of individual movements? That would be like maybe rolling, using a log roll to get out of bed. So you go from laying on your back to rolling on your side to pushing up.
00:43:48
Speaker
Serial tasks are well suited to practicing parts of them. Discrete and continuous tasks, you part practice is not as helpful. Is the task stable or mobile? And here we're not talking about joint stability or you may hear an msk while I'm doing stabilization or mobilization. Here we're talking about the task. We define a stable task as one where the base of support does not move or change.
00:44:19
Speaker
A mobile task has a changing base of support. We'll come back to this later, but that's how we're going to define a stable or mobile task. Does the task involve manipulation? Is there upper extremity use involved or no manipulation? Those are some of the key considerations that we'll have for the task.
00:44:39
Speaker
Then as we think about the environment, environment is usually pretty easy for most people to get a handle on. You think about is it a closed or an open environment?
00:44:50
Speaker
Easiest consideration here is an open environment has a lot of distractions, has a lot of things going on. A closed environment is a predictable and predictable environment, not a lot happening. So most therapy gyms are relatively closed environments, depending upon how much noise is in the background, how many patients are there. Here, a key consideration is if you're always training in a closed environment,
00:45:15
Speaker
But the patient needs to be able eventually to go to Walmart to go shopping. Well, that's a very open environment. So you think about matching the environment you're practicing in towards what the person needs in the long term. You may start out closed and move to open. That's completely appropriate. But you want to have those considerations.
00:45:35
Speaker
And then finally, we think about from the environment, what are regulatory features and non-regulatory? This one's a little bit harder for people to wrap their heads around. Regulatory means that feature of the environment shapes the movement.
00:45:49
Speaker
Non-regulatory means it does not shape the movement. So very simple example would be if I'm doing a sit-to-stand activity in um let's say I'm doing a sit to stand activity in the coffee shop. So I'm done eating. I didn't spare. I'm done drinking my coffee. Didn't spill any of it. Had a great visit with my friend. I'm standing up to walk away.
00:46:09
Speaker
Regulatory feature of the environment is the height of the chair. I need to be able to stand up from that height chair. If I can't stand up from that height chair, I fail the movement. A non-regulatory feature would be the lighting in the coffee shop, all the ambient noise, all the background noise. That's non-regulatory. The non-regulatory features of the environment may impact my movement. I may get distracted, but it's not this I don't have to conform to that to succeed versus I have to conform to the regulatory feature, which is the height of the chair. So that's non-negotiable essentially.
00:46:49
Speaker
Okay, we covered a lot today. We went from motor control theories. We talked about some ideas of how to think about how movement is controlled and developed. We landed on dynamic systems theory as best current evidence for motor control. And we finished by talking about the task-oriented model. So these should give you some ideas of how Therapists initially thought about movement and structuring treatment, and currently we're operating within dynamic systems theory with the task-oriented model. And so your goal moving forward is going to keep thinking about the importance of high repetition, practice, the ability to make mistakes, practice that's a very salient.
00:47:38
Speaker
And then as it relates to movement, thinking of movement being at the intersection of the individual, So can the individual feel things and perceive things coming in?
00:47:50
Speaker
Can they produce a motor output? And what's their overall cognition there? So the individual, the task, thinking about is it a stable or mobile task, et cetera. And the environment, is it an open or closed environment? What features of the environment shape the movement?
00:48:12
Speaker
Thanks for listening to the NeuroPowerHour. your host, Dr. Michael Powers, and I hope to catch you next time to continue learning.