THE USE OF FUNCTIONAL ACTIVITIES IN THERAPY AN INTEGRATION OF THE PRINCIPLES OF MOTOR CONTROL AND THE LEARNING PROCESS

The successful rehabilitation of a patient following a CVA is largely dependent on the effective relearning of previous motor skills or the learning of new skills. An understanding of the components of motor function and control and the principles of the learning process is therefore essential. Functional activities may be used as an optimal means of combining these principles so as to improve the efficacy of physiotherapy treatment. Two case studies are used to illustrate this approach.


INTRODUCTION
Following a CVA, a person rem ains an individual who must function within the surrounding environm ent and community.
Daily life represents a constant challenge and the individual will have to acquire new skills or re-acquire previous skills if they are to cope effectively.These skills m ay be physical, cognitive, psy chological, emotional or social in nature.
M ovem ent is seen as a means by which an individual interacts with the environm ent -a means by w hich problems are solved ' .
Daily tasks present a wide variety of dem ands to the individual; if the person is to function effectively he will not only have to possess certain basic abilities, but he will also have to be an effective problem -solver.
Therapists are interested in the developm ent of competence and in how this degree of com petence is reflected in the individ ual's behaviour and function .However, since it is not possible to cover each precise requirem ent of the wide range of daily tasks facing the client, the therapist will have to integrate treatment principles and techniques aimed at improving motor skills with those aimed at prom oting problem -solving skills.As such, the physiotherapist is not merely a coach of specific movements, "but is in essence a designer of the learning situations''^.

A B S T R A C T
The successful rehabilitation of a patient following a CVA is largely dependent on the effective relearning of previous motor skills or the learning of new skills.An understanding of the components of motor function and control and the principles of the learning process is therefore essential.Functional activities may be used as an optimal means of combining these principles so as to improve the efficacy of physiotherapy treatment.Two case studies are used to illustrate this approach.

MOTOR BEHAVIOUR
The classic view of m otor behaviour is based on the existence of jmotor engrams wjhich are specific to each m otor skill^.These engrams are taken to be stored in the m em ory and to contain detailed muscle-specific inform ation for each movem ent.A con sequence of this view, however, is that there would have to be as many motor programs as there are possibilities to move.Thus the concept of such a rigid motor system has been rejected in favour Following a CVA a person will attem pt to function using undamaged neural systems.By using these com pensatory m echa nisms to achieve his goal, alternative central pattern generators are established and the partially damaged system s will not be stimulated to recover5.This type of fixed com pensatory pattern could greatly limit the persons ability to achieve their full potential ._________________________________ _____________ __One of the main aims of therapy is to re-establish n orm aj 'm ovem ent patterns.An understanding of the principles oflearn-J'Motor learning is n£>t the learning of m uscle control or m ove ment control, butjthe acquisition of program m ing rulesjthat en able the subject to"Behave flexibly under different conditions" .
In this article we will focus on elem ents of learning that can be m anipulated by the therapists.In the authors' opinion, there are four crucial elements w hich will influence the acquisition of these programming rules: ing will enable the therapist to lfacilitate stim ulation of these J vpartially damaged central pattern generators optim ally.J

RELEVANT ASPECTS OF THE LEARNING PROCESS
"A large part of therapy can be seen as a learning process during which clients must m aster new skills (eg.propelling a wheelchair) or must reacquire old skills (eg.w alking)" "Learning is seen as a set of processes associated w ith practice or experience and leading to a relatively stable change in behav-•___lid • Environm ental aspects or context ' • Nature of the task '7 • Type of feedback4,7'8 7 8 • Design of the practice schedule '

E N V IR O N M E N T A L A S P E C T S :
The fam iliarity of the environm ent as well as the type of environm ent (physical, social and cultural) can influence learn ing.Inform ation that can easily be related to previous knowledge, experience and skills will be m ore easily learned and remem bered.Furthermore, know ledge o f and fam iliarity w ith the task affects both processing speed and strategy selection*'.Subsequent to a CVA, an individual m ay have difficulty in accessing previous know ledge and experiences, associating new information with previous experiences, or in being able to elaborate new informa tion.Subsequently, an unfamiliar, crowded environment, filled with visual and auditory distractions, can affect the learner's ability to draw on previous knowledge as well as their attitude towards and ability to process and m onitor inform ation.
-!X llow ing a person to practise skills within an environment with which they are fam iliar or which at least bears a close 'resem blance to a know n environment-can assistin-the-retrieval or -' accessing of previous knowledg^.It has been argued that if what is taught is abstract and removed from the context and conditions o f its application, not only will it be unrelated to previous experi ence, but it will be learnt as an isolated, fragmented entity*'.A person should therefore be trained in the environm ent most appropriate to the type of task and to where the task wilLbepgrformed in the real world, j

TH E N A T U R E O F T H E T A S K
The environm ent places certain demands on motor actions because it influences the choice of motor strategies.As the envi ronment, ie. the surface (terrain), objects and people, may remain stationary or be in motion, tasks may be classified as being either closed or open tasks.

^D E S IG N O F T H E P R A C T IC E S C H E D U L E
, ^ During a treatment session, the therapist uses a specially de Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2013.) CASE 1

H istory
Mrs I A is a 72 year old lady who suffered a CVA on 7 March 1990, resulting in a left sided hemiplegia.She was referred to the Centre for Care and Rehabilitation of the Disabled by a com m u nity nurse more that five years after the incident.Before admis sion, two home visits were made in order to start retraining during the time that she was on the waiting list for admission.She was admitted for in-patient rehabilitation on 12 June 1995 and discharged after seven weeks.A home visit was done subsequent to discharge.

P hysical statu s
Even though active, selective movements were present in both the upper and lower limb, she had a high degree of spasticity.
Together with severe loss of proprioception and tactile sensation in both affected limbs, this often caused her to ignore the left upper limb and it would pull up into a mass flexion spastic pattern.At discharge, she was able to inhibit the mass patterns and use the arm functionally, even though components of the mass pattern were still visible.

S ocial b ac kg ro u n d
Mrs 1 A shares a house with her daughter and granddaughter who is in primary school.Her daughter works full time.After the CVA, Mrs I A resumed her household chores without assistance.Two activities will be discussed, namely, wiping the sink and hanging up the washing.Note the presence of asso ciated reactions in the sec ond and fifth fin g e rs .
T here is m obile w eight b earin g on both lim bs.W eig h t is b ein g tra n s ferred laterally and anteri orly from the right leg be-Fiq 1: Wiping the sink hind, onto the left leg in fro n t, p re p a rin g fo r weight shift during gait.One should be careful that the patient is not only bearing weight on the right hand side.The left upper limb should not be a medial rotation.There should be no retrac tion of the left side of the pelvis, nor should the left knee be hyperextended.

Hanging up washing
The two illustrations show incorrect patterns (Fig. 2) and im proved patterns (Fig. 3).
In figure 2 it is evident that the associated reactions of the upper and lower limbs result in com plete and marked asymmetry.The task is difficult, dem anding very good dynamic standing balance, as well as distal function.As the task is difficult, the tone increases considerably all throughout the body.As she is not using the left with inversion, plantarflexion of the foot.If spasticity during difficult activities is not controlled, spasticity will increase over time, decreasing function at the same time.
In addition, the patient dem onstrates poor back care tech niques and kinetic handling skills.
In figure 3, Mrs IA is repeating the action.Her starting position is unchanged, but she is now using both upper limbs.
The upper limb is now used functionally, despite increased tone still being present.Because of the improved activity in the upper limb, the trunk is now symmetrical.There is still asymme try present in the lower limb, but less than before.
Ideally, the basin should be lifted onto a chair or stool.The problem is that the patient cannot carry a big object like that herself, nor does she want to leave anything outdoors.Back care should be introduced into her home programme.

H istory
Mr G v B is a 26 year old teacher.On 31 August 1995 hesuffered a CVA, resulting in a right sided hemiplegia.At the time of the incident, he was admitted to a private m edical clinic and from there referred to the Centre for Care and Rehabilitation of the Disabled.He spend three weeks at home prior to his admission at the Rehabilitation Centre.In-patient rehabilitation lasted seven weeks.

P h ysical status
On discharge, Mr G v B had good, active, selective movement in his upper limb.Even though proximal tone was slightly de creased, distal tone in hands and fingers was slightly increased.The lower limb had slightly decreased tone, with underlying increased tone, only visible during hard physical activity.

S ocial backg ro u n d
Mr G v B is unmarried and lives with his parents.He shares a bedroom with his brother.Apart from teaching, Mr G v B also has to help with household chores, such as gardening.In his spare time, he reads a lot.Two activities will be discussed, namely, mowing the lawn and reading.----------------------^--------------------------------- A K Suksesvolle rehabilitate van die pasient na SVO is grootliks afhanklik van die effektiewe aanleer van vorige vaardighede of die aanleer van nuwe vaardighede.Dit is van uiterste belang dat die terapeut die komponente van motorfunksie en beheer en die beginsels van die leerproses verstaan.Die effektiwiteit van die fisioterapeutiese behandeling kan verbeter word deur die gebruik van funksionele aktiwiteite.Hierdeur kan bg.beginsels optimaal geintegreer word.Die benadering word deur die gebruik van twee gevalle studies uitgelig.This view has two key features: • in addition to therapeutic skills, know ledge of m otor behav iour is required, as well as an understanding o f the principles underlying the learning process and • the m odern trend of incorporation of specific tasks or activities w ithin treatment sessions should not be limited to the clinical setting, but should be extended to include both the client's hom e environm ent and his hom e-program m e.
of a more flexible model, namely the distributive model of motor control5.This relies on the concept of central pattern generators (groups o f neurons distributed throughout the central nervous system) responsible for the execution of m otor program m es.It is these motor programmes that then result in functional movement synergies which are flexible enough to adapt to sim ilar tasks under different or varying conditions.• varyir^ ( A ccording to Sabari , person n eed s in ta ct (m otor pro-~j_ ^grammes, motor memory, feedback m echanism s .andfeedfor w ard mechanisms for effectiv e jn o to riu n c tioningyHowever, it is "A precisely these mechanisms which are damaged in cases of brain injury.
fclosed tasks: Examples of these tasks include eating, drinking and self-care activities.These tasks can be successfullyltrained or [relearnt by repetition in a stationary environm ent.Transfer occurs weight is equally distributed over both legs w hilst standing.Extrinsic feedback is inform ation from an external source that augments the intrinsic feedback, egTthe therapist, i jwo kinds of extrinsic ieedback-can.be-Riven; know ledge of results (KR) and 'know ledge of performance (KP).r K now ledge of results might b e verbal feedback a^out movem ent outcom e that is given after a m ovement.This provides inform ation about errors a^id will assist the learner in knowing how to modify the movem ent on the next attempt, eg."Y ou r feet are too close together."or "Y ou 're sitting in a slum ped position."Knowledge oLperformance is ( V e r b a l feedback about the nature of j the movement that j s given during a response, eg."Y ou need to shift more weight to your left leg." or "Y ou r strides are not of equal length."Therapists m ore often use this type of feedback as J H s aimed.atxorrecting the movem ent pattern rather than merely j I the outcom e.! Ẽither type of feedback can facilitate and accelerate the learn ing process.

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s i g n e d practice schedule.The therapist can m anipulate several factors of a practice schedule, namely: • rest periods, the order o f skills practised, conditions o f the task and the amount of task that is being practised.JCompared w ith sportsm en who may train eight hours a day or m ore to perfect skills, therapists usually spend no longer than one hour per day retraining m otor skills in stroke victims.Conrelatively easily.O pen tasks: Exam ples of these tasks.includeJcrossinga street, ball games, sitting in a moving train or taxi.These tasks cannot be .trainedsuccessfully by repetition in a stationary environment?/Transfer does.not.occurspontaneously Since the nature o f tasks differ, the demands on postural control and dexterity differ.Also, even in the same task, the conditions of the environm ent m ay change betw een two consecu tive perform ances or even betw een two successive trials.There fore therapists cannot lim it their clients to practising movements eg.flexion/extension, in isolation in the clinical setting with the goal jaf_ imp roving -task perform ance.T nstead ,^T actisIngo7 re learning of tasks or part of tasks should be used in different environm ents and is the only way to im prove task performanceTY P E O F F E E D B A C KFeedback m ay broadly be divided into three areas:• inform ation available prior to movement • inform ation available to guide an ongoing response • i n fo rrna tion .ava i 1 a b 1 e as a result of the movem ent._________ __ in trin sic feed b ack is inherent-sensoiy information from recept ors in the muscles, joints, tendons and skin as well as receptors in the visual and auditory systems/lntrinsic feedback may occur during or after m ovem ent production, ^g. a patient senses his sidexing-the fac-t-that "skill increases directly in relation to the [am ount of practice" , <^neTealises-that-whlTFhappens outside therapy is a s Jm portant as what happens during treatment.It is clear thaLanl effective and relevant hom e-program m e should be jintroduced as early as possible-to ensure m axim al transfer of functional skills practised in th erapy___________________________ R est periods: A rest period of|more than the practice period 'i (distributive practice) is appropria teTor rehabilitation in the acute J stage.M assed practice (rest time less than practice time) is appro priate for final rehabilitation.The practice time refers not only to J the treatment session, and therefore should include a full-time, "Appropriate and integrated hom e programme.Order o f tasks: Practising different tasks a j random (random practice), rather than m aintainine the sameorkarTfblocked_practice) im proves learning as it improves concentration and motor [m em ory. 1 ond ition s o f the task: Variability of the task also improves learning, as the environm ental dem ands m ade on the person change continuously -thereby dem anding heightened concentra tion and at the same time acting as a random practice trial.Am ount o f task: A task can be practised as a(whole, or~just as a part of a tasM.Practising com ponents of a task is useful when relearning com plicated tasks, eg.retraining com ponents o F g a lf before having the patient walking fuhctionaHy7[Part-task training can be used in early rehabilitatioi^ when certain aspects of the task can be used to achieve relevant aims even though execution of the entire task m ay be too difficult or com plicated at that stage; supported standing while dusting is effective since the client is learning to cope with the postural dem ands of the upright posi tion required in preparation for independent dynam ic standing balance.Two case studies will be used to illustrate the above.B la d sy 34 M e i 1996 SA Tydskrif F is io te ra p ie , D e e l 5 2 N o 2

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ta n d in g in w a lkstance, left leg forward, supporting on left upper limb, wiping surface with right upper limb.Segmen tal flexion and rotation are present in the trunk, de pending on how far is be ing reached w ith right hand.Both affected limbs are in inhibitory patterns.

Figure 2 :
Figure 2: Hanging up Figure 3: Hanging up washing -incorrect patterns w ashing -correct patterns

Figure 4 :
Figure 4: M ow ing the lawn -1991:71(2);124-139. 2. Saban J S. M otor learning concepts applied to activity-based interven tion w ith adults w ith hemiplegia.The American journal o f Occupational Therapy 1991:45(6);523-530.3. M ulder T. A process-orientated m odel of hum an behaviour: Toward a The advantages of using a fu n c tio n a l a p p ro a ch which incorporates both the com ponents of motor func tioning and control and the principles of the learning p ro cess have b een h ig h lighted in the above discus sion.Initially, integrating this a p p ro a ch into d aily therapy may demand extrathought and planning from the therapist but the benefit should soon be apparent, as such an approach assists in the e ffe c tiv e tra n sfe r of functional tasks according to the demands of the envi ronment.Since the approach is not only aim ed at im proving motor skill but also at equip ping one's client with problem-solving skills, retention and transfer of that which is learned in therapy sessions should be facilitated.