1. Patient Function (activity/task)
1.1. Patient Strategy
1.1.1. Patient Impairment
2. Assessment Process
2.1. Subjective
2.1.1. Determine participation restrictions.
2.1.2. Gain understanding of environment, task and individual factors that could be contributing to this restriction.
2.1.2.1. E.g. Lesion Location
2.1.3. Set goals based on participation restrictions.
2.1.4. Screen for red flags
2.2. Objective
2.2.1. Test Impairments
2.2.1.1. Determine why they are moving that way: From subjective and objective you should have know the patient's participation restriction, corresponding activity limitation, corresponding abnormal strategy. From this, you should also have hypothesized about the possible impairments that could be causing the poor motor performance. You cannot test everything. Choose 4-5 impairments within the first assessment session to test based on lesion location, subjective and observation. Prioritize the most likely impairments and the tests need to assess them.
2.2.1.1.1. 1st: Motor Tests
2.2.1.1.2. 2nd: Sensory Tests
2.2.2. Observation of Function (activity/task) and Strategies
2.2.2.1. Based on patient's participation restrictions, observe the activities involved in that participation.
2.2.2.1.1. "Patient can't sit down in chair to watch TV" -> observe their sit-to-stand.
3. Patient Impairment
3.1. Patient Strategy
3.1.1. Patient Function (activity/task)
4. Identify Impairment/ Problem List
5. Treatment Process
5.1. Motor Impairments - Weakness - Hypertonia - Poor NMSK Control Maximize motor learning depending on the patient's current ability, stage of motor learning and functional goal.
5.1.1. Task Specific Training
5.1.1.1. First, Identify
5.1.1.1.1. 1) demands of the task within the patient's environmental context. - speed required? - range that muscle is working in? - type of contraction? - repetitions required?
5.1.1.1.2. 2) The type of task (discrete, continuous, serial)
5.1.1.1.3. 3) The patient's stage of motor learning (cognitive, associative, automatic).
5.1.1.2. Based on the above:
5.1.1.2.1. (a) What type of training should be used
5.1.1.2.2. (b) What is the optimal practice structure
5.1.1.2.3. (c) What is the optimal feedback type, schedule & bandwidth
5.1.1.2.4. (d) What requirements of the task should be emphasized during task-specific training? - Can be used to add challenge, varability and manipulate the task to target the person's underlying impairments.
6. Models To Know
6.1. Patient Fx, Strategy, Impairment
6.2. ICF Model
6.2.1. These all correspond with eachother
6.3. Systems Model of Motor Performance
7. Observe
8. Hypothesize & Test
9. Treat impairments in a way that is specific to the functional task/activity
10. Promotes short-term improvement in motor performance (no motor learning)
11. Maximize Motor Learning (IRIS) Principles that underscore training
11.1. Doing what you love - **importance**
11.2. Repetition
11.2.1. More practice = more gains
11.2.2. Clear association between quantity of practice, task improvement and brain reorganization.
11.3. Optimally challenging - **intensity**
11.4. **Specificity **(to desired activity/task)
11.4.1. Training must mimic the specific requirements of the task: - speed of movement - type of muscle actions - range of motion - range of muscle contraction
11.4.1.1. Studies show that although strength training is effective in increasing strength in stroke populations, studies also show a poor association with improved function. Strength does not equal function. This is because there is a missing link. Just because a muscle gets strong, doesn't mean it has adapted to the functional requirements of a task.
12. **Facilitation** Used to provide stimulus or assistance to make it easier to move.
12.1. **Used as an adjunct to Task-Specific Training:** If a patient cannot do a task, it is important that we do not wait! **The longer we wait, neuronal circuits used for a task will degrade.** Instead, we should use **facilitation** to make the tasks easier so that we can maintain those circuits and accelerate the process.
12.1.1. Facilitation helps to increase the number of motor neurons that are firing.
12.1.1.1. Via: increasing Cortical Output
12.1.1.1.1. Voluntary activation of muscle "trying really hard to move"
12.1.1.1.2. Mental Practice/Reherseal of movement
12.1.1.1.3. Bilateral training: training the unaffected side can lead to improvements in affected side.
12.1.1.2. Via: Increasing Motor Output
12.1.1.2.1. **GUIDING:** Therapists uses hands to support and guide patient's movement but patient is still encourage to try as hard as possible.
12.1.1.3. Via: Increasing Sensory Input
12.1.1.3.1. Touch cues
12.1.1.3.2. Weight bearing
12.1.1.3.3. Passive movement
12.1.1.3.4. Visual cues