The Use of Meaningful Activity in Neurological Rehabilitation

1. 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

2. Overview • Introduction to Occupational Therapy • Introduction to CIMT • Application of CIMT in Occupational Therapy • Case Example „Musician“ • Discussion

3. Basic Assumptions in OccupationalTherapy • „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

4. OccupationalTherapy in Motor Controland Motor Learning • Motor controlistheabilitytofixatethebodyandtomovethebody(Gilmore & Spaulding 2001) • Motor learningreferstochanges in movementbehavioras a resultofpracticeorexperience(Gilmore & Spaulding 2001) • Occupationaltherapistsmakeuseofthree different interventions in motorlearning(AOTA 2008): • Preparatorymethods • Useofpurposeful (therapeutic) activities • Engagement in desiredoccupations

5. IntroductiontotheConstraintInduced Movement Therapy (CIMT) • CIMT isbased on thelearneddisuse after theonsetofneurologicaldisorder

6. Development of learned disuse (figure adapted from: brainworksrehab.com) Injury / Stroke Positivelyreinforced Unsuccessfulmotorattempts Feelings offailure Compensatorybehavior Lesseffectivebehaviorstrengthened Behaviorsuppressed Learneddisuseoflimb

7. 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)

8. Introduction to CIMT • Criteriaforapplicationofthe CIMT method(Wolf et al 2006): • ≥6 months post-stroke • Noor mild cognitiveimpairments (MMSE ≥24) • Ambulatorywithouttheuseofassistivedevices • ≥45° shoulderflexionandabduction • 45° externalrotationattheshoulder • Fullelbowextension • 45° forearmsupinationandpronation • ≥ 5° wristextension • 5° digital exension (specificallythumb, index + middlefinger) • Abilitytograspandrelease a washcloth 3 timeswithin 1 min.

9. Applicationof CIMT in OccupationalTherapy • Application of preparatory methods • stretching of the affected upper extremity • joint mobilization • training the strength of the hand • taktile stimulation

10. 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

11. Applicationof CIMT in OccupationalTherapy The chosen preparatory methods and purposeful activities need to match the demands of the desired occupation!

12. Applicationof CIMT in OccupationalTherapy • 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

13. Case Example „Musician“from 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 ADL´s

14. Case Example „Musician“ • Preparatorymethods • Manual stretchingofanatomicstructures • Progressive resistiveexercises • Weightbearingandjointcompression • Performance ofpurposefulactivities • Simulation ofviolinplaying • Engagement in cookingactivities • Arranging a photoalbum

15. 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

16. 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

17. 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 musician´s 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

18. Thankyouforyourattention! Heiko Lorenzen Referent andLecturerforOccupationalTherapy Referent for ICF in Neurological Rehabilitation Referent forFatigue Management Contact: heiko.lorenzen@web.de