Week 7 (parts 1 and 2)

Question 1

part 1

Answer 1

motor and postural control

Question 2

what is motor control

Answer 2

Movement, Overarching theory of how and why we move

Question 3

what is postural control

Answer 3

Stability, Stability before strength – injury prevention

Question 4

what are some motor control theories

Answer 4

 Reflex Theory - Stimulus causes reflex
 Hierarchical Theory - everything is reflexive but different parts of brain have elements of control
 Motor Programming Theories – brain can programme movement/ reflexes more
 Systems Theories
 Dynamical Action Theory
 Ecological Theory

Question 5

what is the systems model of motor control

Answer 5

 The ability to regulate and direct mechanisms of movement
 What characteristics of task, individual and environment will influence movement?
 Requires good underlying postural control
Lateral descending tracts (corticospinal and rubrospinal and lateral reticulospinal)
Environment:
- Terrain
- Temperature
- Obstacles
Task:
- Complexity of the task
- Size of object/ task
- Intensity of the task, discreet or continuous task
Individual:
- Mood – confidence/ emotions
- Physical capabilities (strength, age, Health conditions/ illnesses, fatigue etc)
- Coordination
- ROM

 Most recent physiotherapy texts and research have been based on the systems theory
 Interaction of task, individual and environment.
 Many systems, subsystems and multiple connections within the nervous system working in parallel and hierarchy to produce movement
 Focus therefore clinically on functional tasks rather than trying to ‘fix’ the damaged pathway or circuit
 The focus of research in recent years has moved from looking at parts of the nervous system in isolation to looking more at networks and how things work (or don’t work!) together

Question 6

facts about postural control

Answer 6

 No universal definition – it is one element of motor control
 Posture
 Balance
 Recovery from instability
 Ability to anticipate and correct for potential instability
 A combination of postural orientation (maintaining alignment) and postural stability (balance – maintaining CoG with in BoS)
 Requires some motor control
 Related to medial descending systems (vestibulospinal, medial reticulospinal and tectospinal)
 Sensory information – vision, proprioception, somatosensory and vestibular and integration of this information
 Ability to adjust tone
 Ankle, hip and stepping strategies
 Body schema
 Cerebellum
 Descending motor control from medial systems (vestibulospinal tracts esp)
 Anticipatory reactions (APAs)
 Being balanced (COG in BOS)
 Postural Muscle = Type 1 muscle

Question 7

what does normal movement require

Answer 7

• Requires integration and co-ordination of both postural and motor control – as well as ascending sensory information
  So, what?
   If we need normal motor and postural control to move normally what are the implications for someone with a neurological disorder?
  o How does normal movement relate to the nervous system?
  o Signal to move can’t reach muscle – muscle can’t contract, means no movement
  o Results in reduced stability

Question 8

what is motor learning

Answer 8

 Motor learning is how we learn new movement patterns in healthy people
 Many brain structures involved
 Recovery from injury has similarities to how we learn movement
 Let’s consider how we learn before we put it in the context of injury or disease

Question 9

what are the types of motor learning

Answer 9

 Habituation – learned suppression of a non-noxious response
 Decrease in synaptic activity
 E.g. some vestibular exercises, wearing a new watch
 Sensitisation – increased response to one stimulus that is consistently preceded by a noxious stimulus
 Increase in synaptic activity
 E.g. respond more to gentle rub on the arm if you have just caught your arm on a door handle
 Includes simple conditioning and more complex forms of skill acquisition
 Involves long term potentiation
 Motor skill learning is often broken down into stages:
 Fitts and Posner (1967):
 Cognitive phase
 Associative phase
 Autonomous phase
 Gentile (1972)
 Acquire a movement pattern (regulatory and non-regulatory conditions) (explicit)
 Adaptation, consistency and economy (implicit)
 Think about when you learnt a new skill – can you relate to these phases?
 Regulatory and non-regulatory conditions relate to the environment – regulatory features are those that are necessary for the performance of the task (e.g. the weight of the cup you are picking up) and non-regulatory are those that are present but not required for the task (e.g. the colour of the cup, the radio in the background). These non regulatory conditions can be distracting in the early stages of learning
 Explicit – focus in on the goal
 Implicit – gradually performance becomes unconscious

Question 10

what is associative learning

Answer 10

 Classical conditioning
 Predicting relationship between two stimuli
 An extension of sensitisation
 E.g. Pavlov’s Dogs
 Operant conditioning
 Relationship of behaviour to a consequence (positive or negative)
 Similar neural mechanism to classical conditioning
 E.g. being rewarded for good behaviour
 Procedural learning
 Implicit knowledge
 Cerebellar circuitry
 Declarative learning
 Explicit knowledge
 Temporal circuitry
 Long term potentiation
 Motor learning is not linear
 Early large improvements
 Smaller improvements as skill is developed
 Periods of plateau or even regression – performance (not skill!) is worse, but learning is still occurring.
 In order to learn a motor skill, you need to be able to acquire it, retain it and transfer it (Magill, 2011)
 Ensure you do not muddle performance with learning!

Question 11

how does motor learning relate to physiotherapy

Answer 11

 Use dependent learning
 Repeated task specific practice
 Needs cognition AND some motor output
 Instructive motor learning
 Knowledge of performance
 Change achieved through intentional movement strategies
 Change in response to explicit feedback
 Needs cognition
 Reinforcement motor learning
 Knowledge of results
 Driven by binary outcome-based feedback
 Feedback from success or failure
 Sensori-motor adaptation-based motor learning
 Change driven by sensory prediction errors
 Not reliant on cognition
 Cerebellum!
 Need to select the most appropriate (or mix of appropriate) strategies to manage the patient in front of you.

Question 12

what enhances motor learning

Answer 12

 Practice
 More is better
 Massed v distributed practice
 Constant v variable
 Random v block
 Specificity
 Be task specific
 Transferability
 Whole v part training
 Any impairment focussed work must be transferred to function
 Feedback
 External focus but move from external to internal feedback
 Knowledge of results rather than knowledge of performance
 Mental Practice
 Modelling
 Allow choice
 Please read the following paper:
 Applying priniciples of motor learning
 Applying Principles of motor learning and control to upper extremity rehabilitation – it is linked on canvas

Question 13

part 2

Answer 13

Parkinson’s Disease

Question 14

Parkinson’s facts

Answer 14

• First described by James Parkinson’s in his essay ‘the Shaking Palsy’ (1817)
• It is the second most common neurodegenerative disorder in the world, after Alzheimer’s Disease. In the UK, 130,000-140,000 people have PD (NICE 2017)
• Incidence is 1.5 times higher in males than females.(2)
• Cause for Parkinson’s Disease (PD) remains unknown
• Multicausal - infective / toxic environmental (Lewis, 2016) or Genetic (Hindle, 2010) or some research into the role of gut bacteria

Question 15

what is Parkinson’s disease

Answer 15

• Parkinson’s Disease is one of many disorders under the umbrella of ‘Parkinsonism’
• Parkinson’s UK Website has many resources – here is a video explaining Parkinson’s Disease - Parkinson’s UK
• Parkinson’s disease (PD) is a complex and progressive disorder characterized by various motor and non-motor symptoms (Jankovic, 2008).
• Features of the disease include a resting tremor, rigidity, postural instability, bradykinesia (Mustrafa, 2016)
• A group of grey matter nuclei deeply placed within white matter in the cerebral hemispheres
• Caudate Nucleus
• Putamen
• Globus Pallidus- internal and external segments
• Subthalamic nucleus
• Substantia nigra

Question 16

dopamine pathway facts

Answer 16

• What is dopamine?
• Mesocortical - Cognition, Memory, Attention, Emotion, Behaviour and Learning
• Nigrostriatal – Movement Control
• Mesolimbic - Pleasure, reward seeking behaviours, Addiction, Emotion
• There is a complex interrelationship between these structures and networks

Question 17

what is the circuitry of the Basal Ganglis

Answer 17

• Provides a feedback circuit. It receives information from several sources including the cerebral cortex (sensory and motor areas). The input information enters via the striatum and leaves via the globus pallidus. It feeds this information to the cortex via the thalamus

Question 18

what is the function of the Basal Ganglia

Answer 18

• It is thought to be involved in the initiation of internally generated movements and the execution of complex motor tasks
• It may also be involved in the integration of motor and sensory information (Cohen, 1999)
• The basal ganglia has two main pathways (direct and indirect) that either excite or inhibit output to the motor cortex – a balance between stop and go

Question 19

what is the pathological mechanism of Parkinson’s Disease

Answer 19

• There is a programed destruction of >70% of neurons resulting in depletion of the neurotransmitter dopamine in the substantia nigra (cited in Lennon et al., 2018)
• This leads to changes in the basal ganglia circuitry and the features of PD – e.g., more inhibition (stop) of the thalamus leads to depressed or slow movement
• Impacts limbic and cortical pathways – leading to apathy, memory problems, depression and sleep disorders

Question 20

How is Parkinson’s diagnosed

Answer 20

GP - Bradykinesia
Neurological - Stiffness and/ or tremor

Question 21

what are the three stages of PD

Answer 21

• Preclinical – neurodegeneration present but asymptomatic
• Prodromal Parkinson’s Disease - motor and non-motor symptoms are present with clinical diagnosis
• Clinical Parkinson’s Disease – dopamine-responsive with bradykinesia

Question 22

what are the clinical features of PD

Answer 22

• Bradykinesia (slowness of movement)- suppression of movement in the cortex due to increase inhibition
• Rigidity (stiffness) - typically lead-pipe or cogwheel in the presence of a tremor, due to depletion of dopamine
• Tremor- primarily resting ‘pill rolling’
• Postural Instability (flexed posture)
• Gait- COG anterior, short step length, flexed posture, reduced arm swing, hypokinetic, festinating

Question 23

what are some other ways PD can present

Answer 23

• Handwriting
• Loss of smell
• Slow initiation
• Freezing
• Festination
• Dyskinesia
• Dystonia

Question 24

what are some non-motor features of PD

Answer 24

• Neuropsychiatric symptoms: Depression, Anxiety
• Sleep Disorders: restless legs, insomnia
• Autonomic Symptoms: bladder and bowel, excessive sweating, sexual dysfunction
• Gastrointestinal: constipation
• Dribbling – difficulty managing their saliva
• Sensory Disturbances: pain
• Fatigue
• Nutritional issues / weight loss
• There are 55 acknowledged non-motor symptoms

Question 25

how can PD be managed medically

Answer 25

* Levodopa (dopamine) * Deep brain stimulation surgery

Question 26

how can PD be managed non-medically

Answer 26

* Team management is key * Enable activity * Enable participation * Quality of life * Symptom control

Question 27

what can Physiotherapists offer to PD patients

Answer 27

From early management through to end-of-life support- get all your skills ready! * Mechanical pain – shoulder, lower back * Muscle weakness * Stiffness * Falls and Fractures * Balance * Reduced exercise tolerance – marathon runners! * Social isolation * Reassurance * Functional practice * Pain – neuropathic * Pressure relief * Chest infections * Contractures * Support to family and carers * Advice – t/f, manual handling

Question 28

what is the European physiotherapy guideline for PD

Answer 28

* Self-management * Prevent inactivity * Prevent fear to move and falling * Improve physical capacity * Reduce pain * Delay onset activity limitations * Functional ability- transfers, gait, manual activity * Maintain vital functions * Prevent pressure sores * Prevent contractures * Support carers

Question 29

what should you consider in a PD assessment

Answer 29

* Drug history – timing of medication is vital * Expectations and goals * Carer support * Falls * Non-motor symptoms * Objective Assessment * Observation during functional activities- tremor, dyskinesia, bradykinesia, balance * Range of movement and activity/power - trunk, LL and UL. * When assessing tone feel for - Rigidity- axial rotation, LL, UL * Sensation and proprioception * Coordination * Balance- perturbation, reactions, visual input * Gait - freezing, dual tasking, outdoor/ uneven * Functional - on/off floor, rolling, ly-sit, running, cycling, R&G, car transfers * Confounding factors- processing speed, problem solving, pain, fatigue * Respiratory function and pain management if appropriate

Question 30

what does physiotherapy management do for PD

Answer 30

* Optimise function and independence * Goal setting * Exercise * Practice * Movement strategies * Teamwork * Early intervention * Symptom management * Palliative and carer support

Question 31

what is the purpose of goal setting for PD patients

Answer 31

* Respectful to the individual * Reflects the life of the patient * Builds self-confidence and self-respect * Encourage problem solving skills of your patient * Involve support network and recognises carers

Question 32

what is the UKs Parkinson's Exercise Framework for professionals

Answer 32

Exercise * Progressive resistance strength training * Cardiovascular training * Specific training e.g., Nordic walking/balance training Take Home Message: * 2.5 hours of moderate to vigorous exercise a week, progressive resistance exercise for 2 days a week, specific prescribed exercise (dual tasking /flexibility) 2 times per week. * Keeping active

Question 33

what is some practice and movement strategies

Answer 33

* Practice * Motor skill performance/motor learning * Movement strategies * Teaching strategies to compensate for loss of automatic movement * Cues, attention