Motor Control Theory, Intervention Approaches, and MOVE
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By Patti LaBouff, PT and MOVE International Trainer
MOVE is a program that is designed to teach the motor skills of sitting, transferring, standing and walking to individuals who have severe neuromuscular disabilities. MOVE is based on the new theories of motor control that were first proposed in the 1960's and 1970's, and that form the focus for contemporary movement science research and literature review today. (Bernstein, 1967; Gibson, 1966; Kelso, 1984; Schmidt, 1975). Two current theories of motor control, the motor program theory and the dynamical systems theory, have both integrated concepts from the ecological theory of motor control into their constructs. Consequently, a new clinical intervention approach has evolved that advocates an "ecological model" of motor control. This new approach is called a task-oriented
approach (Shumway-Cook & Woolacott, 2001). The MOVE Program uses a task-oriented approach, and incorporates components from the current motor control and motor learning theories.
Physical and occupational therapists are accustomed to using theoretical models to develop treatment approaches. A reflex theory of motor control was first proposed in 1906 by Sir Charles Sherrington, a neurophysiologist. This theory views movement as a combination or sequence of reflexes. Complex movements were described in terms of compound reflexes and their successive chaining. A stimulus is required at a receptor, and is conducted via a neural pathway to an effector (muscle) which produces a motor response. This structure is known as the reflex arc, and through feedback may produce the next stimulus for the next response (chaining). Over the years, therapists have referred to this concept as a sensory-motor, cause-effect system.
Hierarchical theory was proposed in the 1920's and 1930's by several researchers who used the continuing research of reflexes to make observations and interpretations regarding the role of the higher brain centers as a controlling mechanism. Reflex and hierarchical theories were combined into one, and are referred to as a reflex/hierarchical theory of motor control. This theory views movement as emerging from reflex patterns that are controlled by hierarchically organized levels of the central nervous system. This model uses a top-down structure, in which higher centers control or inhibit activity of the lower centers. In the 1940's, Gesell and McGraw used the reflex/hierarchical theory to describe infant maturation and childhood development.
During the first half of the 1900's, the primary treatment approach used for neuromuscular dysfunction was known as muscle re-education. This technique was effective in the intervention of polio, but was of little use in the treatment of individuals with upper motor neuron lesions. Beginning in the late 1950's through the 1970's, several clinicians began to apply the reflex/hierarchical theory into their clinical practice, and, collectively, these methods became known as "neurofacilitation" approaches. Karl and Berta Bobath proposed the neuro-developmental treatment (NDT) approach. Signe Brunnstrom developed the Brunnstrom approach for CVA patients. Margaret Rood created the neuro-physiological approach and Jean Ayres applied these principals into a sensory integration (SI) theory. Kobat, Knott and Voss developed the proprioceptive neuromuscular facilitation (PNF) system.
These approaches were based primarily on assumptions drawn from the reflex/hierarchical theory and have very little research to support their effectiveness. As we can see from this historical perspective, new theories of motor control were being proposed at about the same time as the neurofacilitation approaches were gaining acceptance in the university-level training programs for physical and occupational therapists. Of particular concern was the lack of research generated at the clinical level as these approaches became established. Subsequently, the field of movement science has identified significant limitations with the neurofacilitation approaches. As we advance into the 21st century, research findings within the fields of motor control and motor learning will challenge therapists to discard the old methods and become students once again to explore the new theories and develop more effective approaches.
Ecological theory was first proposed by James Gibson in 1966, and expanded upon by his students. This model is now known as the ecological approach to motor control. This theory holds that all movements and actions are influenced or constrained by the environment. Environmental information is necessary to shape or modify the characteristics of movement to achieve specific actions or tasks. Whereas previous approaches viewed the individual as a sensory-motor system, this new theory holds that it is not mere sensation that stimulates the response. Of primary importance is the perception of the environmental factors and sensory information that guide the individual to coordinate movements to accomplish a desired goal-directed task. The individual must be viewed as organizing actions that are specific to the desired task within the environment in which the task is being performed.
This ecological model or task-oriented approach has gained wide acceptance among researchers and clinicians alike. During the 1980's and 1990's, many clinicians, including the Bobaths, redefined their approaches to include functional, meaningful activities within the individual's natural environment. Treatment sessions in isolated, clinical settings are to be limited, and opportunities to intervene with individuals within the home, school and community expanded. Routine tasks and daily activities are used as the treatment activities, with therapists providing interventions within the context of the individual's preferences and needs.
For many therapists, this change in approach will prove difficult and confusing. Physical therapists and occupational therapists have been trained within the medical model, which views the clinician as the "expert" and in charge of the patient. Working within the home and school means the therapist must become a member of a team, learn collaboration skills, build relationships and honor each other's expertise as it relates to the individual with disabilities. The therapist can no longer be viewed as the only expert, and is not in charge of the movement program. Rather, the therapist is viewed as a valuable member of a team who, together with the other members, shares expertise to focus on the physical, mental and functional well being of the individual and family.
Fall 2001
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