Occupational Therapy Task-Oriented Approach

1. Traditional approaches to motor controla. Reflex-based, hierarchical, neurofacilitation or neurodevelopment approaches- NDT, PNF, Rood, Brunnstrom2. Contemporary approaches to motor control a.

Task-oriented approachesb. Dynamic Systems Theoryc. Dynamical Systems Approachd. Occupational Therapy Task-Oriented Approach

Movement is task-specific and constrained by the environment.

The individual generates movement in order to accomplish a task of to meet the demands of the environment.

1. Functional tasks help organize motor behavior2.

Occupational performance emerges from the interaction of multiple systems that constitute the unique characteristics of the person and the environment3. After CNS damage or other changes in personal or environmental systems, client's behavioral changes reflect attempts to achieve functional goals4. Practice and active experimentation with varied strategies and in varied contexts are needed to find the optimal solution for a motor problem and to develop skill in performance

1. Conceptualization that movements are controlled by systems cooperating toward the production of movement but without central executive control (1, p. 187)2. Argues that it implausible that the higher cortical centers contain millions of unique programs that tell each muscle what to do, with what force, with what duration and that these are learned by repetition (i.

e., hierarchical model). 3. Instead, belief that the system doesn't have one control center to execute or modify movement but that systems cooperate together toward the production in movement without a central executive control.

4. Hierarchical systems basically the Sensory-Motor-Sensory feedback cycle results in numerous motor programs5. And that movement is a result of the higher centers taking in the sensory input and dispensing the appropriate motor program to perform that movement

Preferred (but not-obligatory) pattern of behavior (i.e.

, movement pattern) that emerges from the interaction of a unique person with a particular task and environment (2)-1. Help to conserve energy (think automatic actions)2. Person typically has stable movement patterns or attractor states with some flexibility3. However, in acute stages of recovery, one can show little stability in attractor states..

.therefore, task performance is not effective or efficient (5, p. 486)

1. A variable (i.e., control parameter) that acts as an agent to cause transition (i.

e., phase shift) behavior from one preferred form to another form, thereby facilitating a reordering of behavior (2)2. A variable whose change can shift a pattern of motor behavior into another pattern (1, p. 187)a.

Person (e.g., pain can cause us to alter movement pattern)b. Environment (e.

g., different writing utensil can cause us to alter movement pattern)CONTROL PARAMETEREnvironment - - Writing on paper vs writing on the board - Changing the type of writing utensil (pencil vs. paint brush)Person --- - Pain - that inhibits a usual movement pattern (back pain - lifting a box)DEGREES of FREEDOM

Child with delayed motor skills catches a ball with a scooping motion (attractor state). A goal of therapy is to improve motor skills and coordination (e.g., catching a ball with hands).

Therapists applies control parameter (e.g., slowing of the throw, lighter ball, bigger ball) and assesses what degree of slowing or weight/size is needed to cause a phase shift (e.g., change from scooping motion to catching with hands)How long it takes to return to scooping motion after control parameters (e.g.

weight, size, speed) are removed?

1. Body dimensions2. Age3. Gender4. Activity level5.

Maturational6. Cognitive7. Affective (motivation)8. Neuronal and non-neuronal changes since CNS damage

1.

Consider the various movement patterns needed to place different objects on a shelf (physical)a. Size, weight, texture, space, etc.A. Other environmental constraints1.Social (e.

g., loading a different dishwasher)2. Cultural (e.g.

, specific way of arranging items)3. Temporal (e.g., in a rush)-Social (are you doing this with someone else, in your kitchen? Their kitchen?Cultural (is there a specific way of arranging items? Are their items that evoke meaning - ingredients of family recipe?)Temporal (in a rush? Preparing the ingredients later tonight?)

1. Factors that serve as major influences on occupational performance (can be personal or environmental).

2. Aim is to help individuals identify and use critical factors that support optimal performance and to determine the optimal value for producing the best performance outcome 3. Critical factors can be organic or environmental- Organic (e.g., strength, balance, visual-perception), Environmental (e.g.

, size or weight of object, position in space)4. Critical factors change over timeNote: Some systems are highly affected immediately after CNS damage while others systems are highly affected later.

Identify tasks that are meaningful and important to client's roles2. Occupation-Baseda.

Describe the movements (attractor states) used for task performance- Determine whether movements are stable or in transition. Effective, efficient, safe?b. Analyze the characteristics of the tasks selected for treatment- Discrete, continuous, serial? Mobility, stability Open, closed?3. Person and Environmenta.

Identify the personal and environmental factors that serve as major influences on occupational performance (critical factors)a. Personal factors, such as: Age, gender, maturation, Body dimensions, Neuronal and non-neuronal, Cognitive, affectiveb. Environmental factors, such as: Physical, social, cultural, etc.4. Stability vs.

Mobilitya. Stability tasks (non-moving base of support)b. Mobility tasks (moving base of support)5. Manipulation continuuma.

Amount of UE involvement in the tasks (dexterity, speed, accuracy)Discrete vs. Continuous vs. Serial (5)Discrete tasks (Beginning and end)Frequent practice of the movement is required to learn and (sometimes to maintain) the skill at a high levelContinuous tasks (No recognizable beginning and end)Generally retained even when there are periods when practice is not possibleSerial tasks (Series of discrete movements)

1. Describe the movements (attractor states) used for task performancea. Determine whether movements are stable or in transition.b.

Effective, efficient, safe?2. Analyze the characteristics of the tasks selected for treatmenta. Discrete, continuous, serial?b. Mobility, stability?c. Open, closed?

Identify the personal and environmental factors that serve as major influences on occupational performance (critical factors)1.

Personal factors, such as:a. Age, gender, maturationb. Body dimensionsc. Neuronal and non-neuronald. Cognitive, affective2. Environmental factors, such as:a.

Physical, social, cultural, etc.

1. Stability vs. Mobilitya.

Stability tasks (non-moving base of support)b. Mobility tasks (moving base of support)2. Manipulation continuuma. Amount of UE involvement in the tasks (dexterity, speed, accuracy)

1.

Discrete tasks (Beginning and end)a. Frequent practice of the movement is required to learn and (sometimes to maintain) the skill at a high level2. Continuous tasks (No recognizable beginning and end)a. Generally retained even when there are periods when practice is not possible3.

Serial tasks (Series of discrete movements)--Discrete: tying a shoe, hitting a baseball (position, load when ball leaves pitcher's hand, turn hips, pull with leading arm, watch ball until point of contact, maintain head position at point where contact occurred rather than watching your ball)Continuous: balancing (in general), walkingSerial: hitting a baseball (position, load when ball leaves pitcher's hand, turn hips, pull with leading arm, watch ball until point of contact, maintain head position at point where contact occurred rather than watching your ball)

1. Closed tasks (stable and predictable environments)a. Example: Showering2. Open tasks (changing and unpredictable environments)a. Often complex placing more demands on the personb.

Example: Driving a car

1. Select and use functional tasks that are meaningful and important to client's roles 2. Anticipate how personal and environmental factors that influence occupational performance will or can change 3. Address critical factors (personal and environmental) to change occupational performance. Alter variables until the control parameter is identified as indicated when a shift (Phase shift) in motor behavior is observable4. Treat neural and non-neural factors of the sensorimotor system that interfere with optimal occupational performancea.

E.g., increase in muscle strength is related to improved functional performance in clients with hemiparesis (8)5. Adapt the task or broader environment to promote optimal occupational performancea. Modify task initially so learner can succeedb.

To alter movement patterns: Use varied size, length, or weight, Change speed or accuracy, Social reinforcement6. Select and use functional tasks that are meaningful and important to client's roles7. Anticipate how personal and environmental factors that influence occupational performance will or can change 8. Address critical factors (personal and environmental) to change occupational performance- Alter variables until the control parameter is identified as indicated when a shift (Phase shift) in motor behavior is observableStructure practice of the task to promote motor learningRandom practice is better than blocked practiceRandom practice would be practicing a variety of closely related tasks within one session (e.

g. varied dressing tasks)Blocked practice would be presenting a series of steps that must be practiced again and again in the same manner (e.g., donning/doffing shirt)NOTE: Performance may look worse with random practice vs.

blocked practice; however, this is OK because the objective is to enhance motor learning and the capability for later performance

1. Use natural objects and environments a. Research shows that reaching tasks enriched with natural objects result in more efficient, direct, smooth and planned movements than reaching tasks without natural objectsb. Rehabilitation environments should simulate real-life setting as much as possible

1. Treat neural and non-neural factors of the sensorimotor system that interfere with optimal occupational performance (8)a.

E.g., increase in muscle strength is related to improved functional performance in clients with hemiparesis (8)2. Adapt the task or broader environment to promote optimal occupational performance (8)a. Modify task initially so learner can succeedb.

To alter movement patterns:Use varied size, length, or weight , Change speed or accuracy, Social reinforcement

Structure practice of the task to promote motor learning-Random practice is better than blocked practice1. Random practice would be practicing a variety of closely related tasks within one session (e.g. varied dressing tasks)2.

Blocked practice would be presenting a series of steps that must be practiced again and again in the same manner (e.g., donning/doffing shirt)3. NOTE: Performance may look worse with random practice vs. blocked practice; however, this is OK because the objective is to enhance motor learning and the capability for later performance--Random practice: Putting of a jacket, putting on a jacket on doll, zipping the doll's jacket, zipping your own jacketTracing letter "a" on sand paper, making circles on paper, looking for the letter "a"Blocked practice:Button shirt, unbutton.

..10 timesWriting letter over and over

Structure practice of the task to promote motor learning- Use strategies to vary the context within a task1. Manipulation of tasks dimensionsa. Support surfacesb. Objects and equipmentc.

Task demandsd. Required information2. Varied context promote development of preferred movement patterns for specific contexts and flexibility in movement patterns for different contexts---Easel, chalkboard, notebook, flat deskPencil grip, crayon, cool marker, orthoticWrite on line, write around a circleChange instructions, change desired outcomes.

Design practice sessions to fit the type of task and learning strategiesA. Whole vs.

Part Learning1. Whole learninga. Generally preferred for continuous and discrete tasksb. Preferred for relatively simple tasks2. Part learninga.

Generally preferred for learning discrete components of serial taskb. Preferred for complex tasks

Design practice sessions to fit the type of task and learning strategiesA. Explicit vs.

Implicit Learning1. Explicit learninga. Requires conscious learning of rules for task performance2. Implicit learninga. Requires learning how to do the task on an unconscious levelb. Is facilitated by structuring the environment and practice of the task--Explicit - following a recipeImplicit - dressing, grooming, 1.

Often for individuals with motor control problems they are having to relearn a task previously learned and performed implicitly...making it structured can be helpful2. Another point, giving the cues can trigger implicit memory/learning centers and yield better performance - (giving someone a shirt to put on without explicit instruction).

3. Dog example - reaching across midline with no context, pure movement focused---compared to petting a dog.

Provide feedback that facilitates motor learning. Feedback is the info received about performance while learning a new skill.

A. Types of Feedback1. Intrinsic Feedbacka. Gathered through sensory avenues (e.g., vision and proprioception)b.

Feedback is compared to learned reference of correct movement to detect errors and correct movement2. Extrinsic Feedbacka. Often verbal feedback to the learner about task success and performanceB. Motor learning requires opportunities for self-assessment and self-correction.1. How do therapists facilitate this process?2.

How do we halt or interfere with this process?3. Does the type of feedback matter? Idea of what is absolutely necessary--Yoga examples -- intrinsic (feedback from your senses) vs extrinsic feedback from the instructor.Often need to allow for delayed processing prior to giving extrinsic feedback.

1. Knowledge of results (information about the movement outcome..

.task success)a. What was the outcome?2. Knowledge of the performance (information about the correctness of the movement pattern that the learner makes...

task performance)a. How did the movement feel?

1. Research indicates that too much extrinsic feedback can be counter-productive to the individual's learning...

a. If it interferes with their processing of intrinsic information about the movement skill orb. If it interferes with their developing error detection capability2. For persons without motor problems:a.

Research states that feedback should be less frequent, random or intermittent, faded over time, & given as summary information3. However, when applied to individuals post stroke:a. Results have demonstrated improved performance consistency but not improved accuracy...more research needs to be done (8, p.

496)

Encourage experimentation with solutions to occupational performance problems (8)1. Guidance learninga. Physically guiding the learner through the task to be learnedb. Used at the outset of teaching a task to acquaint the performer with characteristics of the task to be learned 2. Discovery learninga. Trial and error learning by the learnerb.

May be less effective for acquisition of the skillc. But is more effective for later retention and transfer

Encourage experimentation with solutions to occupational performance problems-1. Feedback should take the form of coaching the client during learning by:a. Directing the focus to the functional outcomeb. Suggesting movements to tryc. Recording progressd.

Assisting with decision making with new challengese. Provide manual guidance if necessary, but allow some elements to vary so that person can experiment with movement patternsf. Fade assistance provided through handling ASAP

1. Discover the optimal movement patterns for task performance2. Achieve flexibility, efficiency, and effectiveness in task performance3. Develop problem-solving skills in clients so they can identify their own solutions to occupational performance problems in home and community

1.

Constraint of unaffected (or less affected) limb a. Using cast, splint, sling, mit, glove2. Completion of one-handed activities using affected limba. For specific period of time (hrs/day/week)b. Progressive task practicec. Provide assistance as necessary to complete task3.

Population: a. Persons with hemiplegia (e.g., stroke, TBI, CP)

1.

Completion of bilateral activities using affected limba. For specific period of time (hrs/day/week)b. Progressive task practicec. Provide assistance as necessary to complete task2. Population: a.

Persons with hemiplegia (e.g., stroke, TBI, CP)

1. Child-centered, goal-oriented approach2. Involves a child-directed, problem-solving process (i.

e., goal-plan-do-check) to carry out motor task3. Emphasis is on guided discovery and use of cognitive strategy to effectively perform motor tasks4. Therapists should refrain from identifying solutions or prompting child to perform task a certain way5. Population: a.

Children with DCD but being investigated for ASD and CP