Chapter 2: Interventions to Improve Motor Function

INTRODUCTION

Careful examination and evaluation of impairments, activity limitations, and participation restrictions enable the therapist to identify movement deficiencies to target during rehabilitation. Restorative interventions focus on targeted movement deficiencies and utilize activity-based interventions and motor learning strategies. To be most effective, restorative interventions include three basic elements: (1) repetitive and intense practice of task-oriented, functional activities; (2) strategies that enhance active motor learning and adherence-enhancing behaviors; and (3) strategies that encourage use of more-impaired body segments while limiting use of less-impaired segments. During early recovery, patients with limited motor function who are unable to perform voluntary movements or have limited control (e.g., patients with stroke or traumatic brain injury [TBI]) may benefit from augmented intervention strategies. This is a more hands-on approach to training that includes guided, assisted, or facilitated movements. Neuromotor approaches such as proprioceptive neuromuscular facilitation (PNF) and neurodevelopmental treatment (NDT) are examples of augmented intervention approaches that incorporate a number of strategies and techniques to promote movement. Patients with severe movement deficiencies, limited recovery potential, and multiple comorbidities and impairments (e.g., the patient with severe stroke and severe cardiac and respiratory compromise) benefit from compensatory intervention strategies designed to promote early resumption of function. Compensatory interventions include altered movement strategies, assistive devices, environmental adaptation, and the use of less-involved body segments for function.

Restorative interventions organized around a behavioral goal meaningful to the patient and specific activities are the best way to promote functional recovery and retention. Impairment-specific interventions that target specific impairments (e.g., spasticity, contracture, weakness) may be necessary during the course of treatment but should not be the primary focus of treatment. The intended outcome of any rehabilitation plan of care (POC) is functional independence. Remediation of specific impairments can be built into a functional training activity. For example, in a hooklying position, lower trunk rotation in which the knees move from side to side (knee rocks) can increase the strength of hip extensors and abductors while reducing the effects of increased lower extremity (LE) extensor hypertonicity. Functionally, it promotes independent bed mobility as a part-task of rolling.

The diversity of problems experienced by the patient with disordered motor function negates the idea that any one approach or intervention strategy can be successful for all patients. As patients recover, their needs and functional abilities change. The successful therapist understands the full continuum of intervention strategies available to aid patients with impaired motor function and uses them effectively during rehabilitation (Box 2.1).