Muscles, Nerves and Movement Third edition Barbara Tyldesley

12 Motor Control Spinal mechanisms short period. Examples of open-loop movements Muscle stretch reflex, Golgi tendon reflex, are pressing a key on a keyboard, throwing a ball spinal integration and synergy and chopping vegetables. However, most actions Descending motor system take longer. In these closed-loop movements, Motor commands to the muscles: the motor commands can be modified during the corticobulbospinal tracts progress of the movement in response to feedback Postural control: brain stem motor centres from the sensory system. and descending pathways Planning, co-ordination and motor learning The cortical motor areas, together with the basal Basal ganglia and cerebellum ganglia and the cerebellum, form the higher cen- Summary of the three levels of motor control tres for the production and regulation of the motor commands to the muscles. Motor nuclei in the The motor system moves the arms in skilful activ- brain stem control the posture and the balance ity and the legs in walking, and at the same time of the body as the movement proceeds. Motor controls the background posture of the whole body. commands reaching the spinal level are fine tuned The same system is involved in movements of the as a result of a variety of influences from the tongue, lips and larynx needed for speech. Move- descending pathways from the brain and from local ments are controlled by motor centres in the brain spinal reflexes. and activity passes down from these motor centres in descending pathways to the motor neurones of In this chapter, activity at the spinal level will be the cranial nerves in the movements of speaking, considered first, followed by the influence of eating and facial expressions, and to the motor descending pathways from the brain stem and the neurones of spinal nerves in the movements of the higher centres. limbs and trunk. SPINAL MECHANISMS Movement is executed in response to commands from the motor centres of the brain. The com- In the spinal cord, the lower motor neurones form mands have been called motor programmes, the final common pathway for activation of the which specify not only which muscles are activat- muscles in all movement, both voluntary and reflex. ed but also the force, direction and timing of Chapter 1 included a description of how the cell the activity. Motor programmes, developed with bodies of the lower motor neurones lie in the ante- practice and stored in the brain, can be activated rior horn of the spinal cord and in the nuclei of the by internal decision making and/or input from the cranial nerves. The axons of the lower motor environment. neurones lie in the peripheral nerves supplying the muscles (see Chapter 1, Fig. 1.15). In simple ballistic movements, known as open loop, the action is planned and executed over a very The spinal cord also contains interneurones, in larger numbers than the motor neurones. An

194 Muscles, Nerves and Movement interneurone is a nerve cell found in the central fusimotor neurones, the spindle becomes slack and nervous system with no branches in a peripheral only responds to marked changes in length of the nerve. The abundance of interneurones reflects the muscle (Fig. 12.1b). In this way, spinal stretch reflex complex information processing performed by the activity is regulated during movement by the high- spinal cord. Interneurones provide an inhibitory er levels of the central nervous system. influence for the regulation of activity in the lower motor neurones and for the reciprocal inhibition Consider the hand performing fine manipulative of antagonist muscles. Interneurones are important movements, such as doing up buttons and tieing in all bilateral movements when there is activity on shoe laces. Stretch reflex activity must be damp- both sides of the spinal cord, and in movement pat- ened in the muscles of the hand to allow rapid terns when several adjacent spinal segments are length changes to occur. At the same time, muscles involved. The spread of activity across the spinal of the shoulder and arm perform background cord by interneurones is the basis of associated activity to hold the postion of the limb and allow reactions. the fingers to move accurately. The spindles in the supporting muscles are set at a high level, so that • ASK a partner to remove an elastic band placed any change in length is resisted. round the fingers and thumb of one hand without using the other hand. Watch how the complex Static and dynamic intrafusal fibres movements attempting to release the fingers from Looking in more detail at the structure of the the band are mirrored in the untied hand. muscle spindle, two different types of intrafusal fibre can be identified. Both types have a primary The associated reaction movements may become sensory ending wound round the central area, the exaggerated when the interruption of descending annulospiral ending. In addition, some of the pathways releases spinal reflexes from the control intrafusal fibres have secondary sensory endings by higher centres. towards the periphery of the fibre, known as flower- spray endings, which respond to the rate of Lower motor neurone activity controls the change in length of the muscle during movement. changes in the length and tension of all the active The two types of intrafusal fibre are: (i) nuclear bag muscles as the body moves from one position to fibres with a bulge in the middle where the nuclei another. Two spinal reflexes provide the basis are found, and secondary sensory endings are pres- for the regulation of these changes to achieve ent; and (ii) nuclear chain fibres, which are thin- co-ordinated movement. The two reflexes are ner and their nuclei are lined up in a row. the muscle stretch reflex and the Golgi tendon reflex. The nuclear bag (dynamic) fibres respond to rapid changes in length of the muscle, while the Muscle stretch reflex nuclear chain (static) fibres respond to prolonged slow stretch. The muscles spindles, therefore, When the body holds a position, muscles are relay detailed information to the spinal cord maintained at a constant length by activity in the about both the length, and the rate of change in muscle stretch reflex (see Chapter 1, muscle length, of a muscle during movement. tone). During movement, muscles change in length, and the level of stretch reflex activity is then The muscle stretch reflex provides a feedback modified by the influence of descending pathways mechanism so that muscle groups producing in the spinal cord which change the setting of the movement change length appropriately and sup- spindles in the following way. Fusimotor (gamma) porting muscles are held at the desired length. neurones supply the intrafusal muscle fibres of the spindles themselves. When these neurones are Golgi tendon reflex excited, the intrafusal fibres of the spindle contract. The spindle then becomes taut and more sensitive Golgi tendon organs are proprioceptors found at to length changes in the muscle (Fig. 12.1a). When the junction between the muscle fibres and the ten- the influence from the descending tracts inhibits don of a muscle. Each consists of a nerve ending embedded in collagen fibrils surrounded by a cap- sule. Since the Golgi tendon organs lie in series

Motor Control 195 Fig. 12.1 Muscle spindle sensitivity: (a) high – descending pathways stimulate fusimotor neurones, the intrafusal fibres contract and the muscle spindle is very sensitive to distortion; (b) low – descending pathways inhibit fusimotor neurones, intrafusal fibres are slack and the muscle spindle is less sensitive to distortion. with the muscle fibres, they respond to an increase tension develops in a muscle. In these conditions, in tension in the whole muscle. (Remember that stimulation of the tendon organs inhibits the lower muscle spindles lie in parallel and respond to a motor neurones and a loss of muscle tension change in length of a muscle.) When the tension occurs. An example is a weight-lifter who experi- in a muscle rises, the muscle pulls on the tendon ences a sudden loss of power when attempting to and the Golgi tendon organs are stimulated. This lift a load that he cannot move. activity stimulates sensory neurones, which synapse with interneurones in the spinal cord. The The two spinal reflexes described, which are interneurones are inhibitory to the lower motor mediated by muscle spindles and Golgi tendon neurones of the same muscle (Fig. 12.2) and also organs, co-operate to control the length and ten- exert an influence on motor neurones supplying sion in the muscles at the correct levels during other muscles around the same joint. In this way, normal movement. the Golgi tendon reflex provides a feedback mechanism to regulate muscle tension and to keep Spinal integration and synergy it within the limits required for the performance of any task. The motor neurones in the spinal cord are organ- ised systematically. Motor neurones of flexor mus- It has been suggested that the Golgi tendon cles lie laterally and extensor motor neurones lie reflex can act as a protective mechanism to prevent medially in each anterior horn of grey matter. damage to tendons when a sudden high level of Motor neurones of the proximal muscles of a limb

196 Muscles, Nerves and Movement Fig. 12.2 Golgi tendon reflex. Fig. 12.4 Inhibitory neurones: (a) presynaptic inhibition; (b) recurrent inhibition. lie towards the centre and those of the distal mus- Inhibition is the term for the changes in the cell cles lie towards the periphery in the grey matter. membrane of a neurone that make it more difficult A large number of interneurones link all of these for it to respond to activity from another source. groups of neurones, forming a neural network. The balance of excitatory and inhibitory influences within a network of neurones determines the final Within a network of neurones, the axon of each output. There are two main types of inhibition in neurone branches to synapse with many other the spinal cord: presynaptic inhibition and recur- neurones (divergence) and each cell body receives rent inhibition (Renshaw cells). branches from many other neurones (conver- gence) (Fig. 12.3). Some of the neurones in a Presynaptic inhibition occurs when the neuro- network will exert excitatory influences, while transmitter substance from a terminal bouton others will inhibit activity. of an inhibitory interneurone prevents the release of excitatory neurotransmitter by another neurone Fig. 12.3 Neurone circuits: (a) convergence; (b) diver- at a synapse (Fig. 12.4a). An example of pre- gence. synaptic inhibition is found in the pain gate mechanism that regulates the activity of the pain transmission cells (see Chapter 11). Another example is the suppression of stretch reflex activity by descending pathways from the brain via spinal interneurones. Recurrent inhibition occurs in the skeletomotor neurones when collaterals or branches of the axons synapse with small inhibitory interneurones called Renshaw cells in the spinal grey matter. The inhibitory neurones, in turn, synapse with the cell bodies of the skeletomotor neurones supplying the same muscle and synergistic muscles (Fig. 12.4b). It has been proposed that the Renshaw cells form a closed-loop feedback control system for alpha- motor neurone activity at the spinal level.

Motor Control 197 Functional movements involve the repetition of Upper motor neurones synapse at all levels in the particular patterns of muscle activity to perform spinal cord with skeletomotor neurones supplying specific tasks. Reach and grasp movements require type I and type II muscle fibres (see Chapter 1), and simultaneous activity in the flexors of the shoulder, also with fusimotor neurones innervating the the extensors of the elbow and wrist, and the flex- intrafusal fibres of muscle spindles. In this way, the ors of the fingers. Walking involves the repetition upper motor neurones affect both the recruitment of alternating flexion and extension movements of motor units for different levels of muscle of the hip, knee and ankle in a particular order. activity, and the level of stretch reflex activity in the These patterns of movement are called synergies. muscles for the regulation of postural tone. Movement synergies are executed by spinal neural networks, containing motor neurones and inter- Motor commands to the muscles: neurones, which generate repeated activity in the corticobulbospinal tracts same groups of neurones. Upper motor neurones originating in the cortical Clinical note-pad 12A: Lower motor motor areas form a fast, direct route via the brain neurone lesion stem and the spinal cord to the lower motor neu- Interruption of lower motor neurones may be rones. The motor areas contributing to this des- due to damage of the cells in the anterior horn cending pathway are the primary motor cortex, the of the spinal cord (for example in poliomyelitis) premotor cortex and the supplementary motor area or to the axons in peripheral nerves (for exam- (see Chapter 3). The neurones in the primary ple in peripheral nerve injury). The result is loss motor cortex are large pyramidal cells with large- of tendon reflexes, and of muscle tone in the diameter, fast-conducting axons. The individual absence of stretch reflex activity. The muscles tracts in this descending system are the lateral and usually feel limp and have no ‘life’ (hypotonia). anterior corticospinal tracts, and the corticobulbar Muscle wasting occurs with time and there is a (or corticonuclear) tract. risk of contractures (see Clinical note-pad 1A). Note that hypertonia can occur in a limb in lower The corticospinal tracts descend from the cere- motor neurone lesion when there is overactivity bral cortex through the brain stem to the spinal cord. in the unaffected muscles. The corticospinal fibres converge as they enter the internal capsule (see Chapter 3, Fig. 3.14). Passing DESCENDING MOTOR SYSTEM into the brain stem, the fibres lie anteriorly in the midbrain and continue down through the pons. At Motor centres in the cerebral cortex plan and ini- the level of the medulla, 85% of the fibres cross to tiate motor commands to the brain stem and the the opposite side and enter the lateral white matter spinal cord. In the brain stem, the background pos- of the spinal cord to become the lateral corticospinal ture and balance during movement is regulated by tract. The other fibres continue anteriorly in the other motor centres that receive background white matter of the spinal cord as the anterior cor- information about the position of the head and ticospinal tract. The area where the fibres cross in body, and about the visual field ahead. The axons the medulla is known as the decussation of the pyr- of the neurones in all these motor centres in the amids (see Fig. 3.17c). The anterior corticospinal brain lie in tracts that terminate at all levels in the fibres cross at the level of the segment that they sup- spinal cord. Together they form the descending ply. Fibres of both tracts terminate in the spinal cord, motor system. The neurones in this system are where they synapse with lower motor neurones known as upper motor neurones. The collective either directly or via interneurones. Figure 12.5 output from these upper motor neurones influ- shows the route followed by the corticospinal tracts. ences the level of activity in the lower motor neu- rones of the spinal cord which, in turn, controls the The corticobulbar tract originates in the same active muscles during movement. cortical areas as the corticospinal pathway. A large part of the corticobulbar tract ends in the brain stem in the motor nuclei of cranial nerves, the red nucle- us and the motor nuclei of the reticular formation. The corticobulbar tract activates the muscles

198 Muscles, Nerves and Movement Fig. 12.5 Corticospinal tracts seen in frontal section of the brain with the spinal cord. Position of the tracts in a transverse section of the spinal cord. involved in eye movements, facial expression and In the corticospinal component, muscle action on speech via the links with cranial nerves. The influ- one side of the body is initiated by the motor areas ence of the corticobulbar tract also extends to the of the opposite cerebral cortex. Muscle activation spinal cord via the links with the brain stem motor by the corticobulbar component is either ipsilater- centres and their descending tracts. al or contralateral, depending on the target brain stem nucleus involved. The corticospinal system Together, the corticospinal and corticobulbar plays a major role in the control of skilled preci- tracts represent the cortical descending system for sion movements of the distal muscles of the limbs, the motor commands to the muscles in movement.

Motor Control 199 while the corticobulbar system controls movements limbs. Their effect on the fusimotor neurones is of the eyes and the face inhibitory, which eliminates unwanted tone, so allowing skilful movement to take place. Postural control: brain stem motor centres Figure 12.6 shows the motor centres in the brain stem and their descending tracts to the spinal cord. The motor centres in the brain stem are the origin of descending tracts that terminate by synapse with The tectum of the midbrain contains two pairs lower motor neurones in the spinal cord. Overall, of nuclei, the superior and inferior colliculli. Visu- the fibres of these tracts are excitatory to the skele- al and auditory information is processed in these tomotor neurones of the extensor muscles of the nuclei. The output from these nuclei is to the cer- neck and trunk, and the proximal muscles of the vical segments of the spinal cord via the tectospinal tract and to the muscles of the neck. This pathway initiates changes in the position of the head in Fig. 12.6 Motor centres in the brain stem (diagrammatic). Origin of the descending tracts from the brain stem.

200 Muscles, Nerves and Movement response to sound and to changes in the visual field. • stabilise the position of the head and the eyes Examples of this response are experienced when a • provide proximal support during skilled move- person turns towards the sound of someone call- ing their name, or towards a car overtaking them ment of the hands and feet in driving. In group sports, a player responds to the • maintain activity in extensor antigravity muscles position of other members of the team from the sound and sight of their changing positions. to keep the body upright. The red nucleus in the midbrain (sometimes Clinical note-pad 12B: Upper motor included with the basal ganglia) is a motor nucle- neurone lesion us that receives input from the cerebellum and the Interruption of upper motor neurones may be primary motor area. The descending pathway from due to a cerebral vascular accident, traumatic the red nucleus to the lower motor neurones of the brain injury or cerebral tumour. The outcome is spinal cord is the rubrospinal tract. This is an variable. Lesions can cause increased tendon important route from the cerebellum, which has no reflexes and spasticity owing to loss of higher direct descending pathway to the spinal cord. The centre control of the stretch reflex. Movement rubrospinal tract is closely linked with the corti- is often most affected in the fine co-ordinated cospinal tract for the activation of the proximal flex- movements of the fingers and hands. Abnormal or muscles of the limbs, which provide support movement patterns may appear. The upper limb during movement. may show flexor synergy, and the lower limb may demonstrate an extensor synergy, so that normal The vestibular nucleus in the medulla receives movements are difficult to perform. There is a input from the vestibule of the ear (see Chapter risk of muscle contracture. 11). The descending tracts from the vestibular nucleus activate the muscles of the neck, which sta- Hemiplegia is an upper motor neurone bilise the position of the head. Some fibres of the lesion causing motor and/or sensory loss on one vestibulospinal tract continue to all levels of the side of the body. It is usually due to damage in spinal cord, innervating predominantly extensor the contralateral cerebral hemisphere, or to the motor neurones for postural control. The vestibu- brain stem above the level of crossing of the lar nucleus is part of the vestibulo-ocular reflex, corticospinal tracts in the medulla. which controls eye movements when the head turns (see Chapter 11, the visual system). Terminology The upper motor neurones have been divided into: The reticular formation, which extends along the core of the brainstem, is a collection of nuclei that • the pyramidal system for the direct descending are loosely connected. The reticular formation pathway from the cortical motor areas to the receives ascending somatosensory information lower motor neurones from the spinal cord, and also descending fibres from the cerebral cortex that terminate bilateral- • the extrapyramidal system for all the other ly. There are two descending reticulospinal tracts. descending pathways from the brain to the lower The function of the lateral tract, which originates motor neurones. These routes are largely poly- in the medulla, is in positioning and support by the synaptic. proximal muscles of the limbs during movement. The medial reticulospinal tract, which originates in A distinction between the pyramidal and extra- the pons, is more concerned with the activation of pyramidal systems was originally based on the the extensor muscles of the neck and trunk to main- assumption that the pyramidal system, originating tain the upright posture and the balance of the in the cortical motor areas, is concerned with whole body. voluntary movement; while the extrapyramidal system, originating in the brain stem, is involved Summary in background postural activity during movement. The descending pathways from the brain stem This distinction is not reflected in the clinical motor centres together form a part of the motor features of upper motor neurone lesions and the system that regulates activity in the muscles to: terms are no longer used in most up-to-date textbooks.

Motor Control 201 PLANNING, CO-ORDINATION AND The exact way in which the basal ganglia influ- MOTOR LEARNING ence movement remains unclear. There is evidence that the activity in the neurones linking the basal The basal ganglia and the cerebellum regulate ganglia to the thalamus is inhibitory. This has led movement as it progresses by interaction with the to the hypothesis that the basal ganglia act as a cortical and brain stem motor centres. Their influ- braking system for motor control. Variations in the ence on movement is exerted via the descending level of this inhibition could affect movement per- pathways from these centres. There are no direct formance in several different ways: unwanted descending pathways from the basal ganglia and movements are eliminated when inhibition is cerebellum to the spinal level. The basal ganglia increased; movements are initiated when the inhi- form motor control loops with the cortical motor bition is removed; and the sequential stages in a centres of the same side, while the cerebellum complex movement are started and stopped by the interacts with the contralateral cerebral cortex. alternation of low and high levels of inhibition, respectively. The variation in the level of inhibition Basal ganglia in the basal ganglia system could explain some of the features of diseases of the basal ganglia, which The individual nuclei of the basal ganglia link range from the presence of involuntary sponta- together to form a functional unit. Information neous movements (hyperkinesia) to a poverty of enters the basal ganglia system from almost all movement with an inability to initiate voluntary areas of the cerebral cortex, especially from the movements (hypokinesia). motor areas and the somatosensory cortex. Output from the basal ganglia projects back to the cortex The basal ganglia play a role in motor planning. of the same side via the thalamus. Two control Some of the information entering the basal ganglia loops are formed in this way: (i) cortex, caudate and system originates in the supplementary motor area putamen (striatum), globus pallidus, thalamus, of the cerebral cortex, which is active before a cortex; and (ii) cortex, caudate and putamen movements starts. Other sources of input are from (striatum), substantia nigra, thalamus, cortex (Fig. the somatosensory area and premotor area, which 12.7). These two motor loops act independently have links with the sensory system monitoring the and in parallel. current environment. Some movements are initi- ated by internal decision making. For example, Somatosensory, premotor and motor cortex when a person decides to switch on the television, a motor plan is activated that selects the correct Thalamus Caudate and motor programme for the execution of this action. putamen This type of movement occurs when a patient is asked to perform a movement to command. Globus Other movements are generated more by sensory STh pallidus input from the environment, for example by the visual input from objects or the sound of a doorbell. In this case, the environmental stimuli facilitate the activation of motor programmes to initiate the movement. Patients with basal ganglia disease have difficulty in initiating movements, par- ticularly those that are internally generated, and they can be assisted by cueing, which provides additional sensory input. Subatania Cerebellum nigra The cerebellum is not necessary for the generation Fig. 12.7 Motor control loop between the basal ganglia of movement. However, it plays a major role in and motor centres in the cortex. the regulation of movement and posture indirectly

202 Muscles, Nerves and Movement by adjusting the output of the descending motor Theories of cerebellar function systems of the brain. The cerebellum is said to Current theories on how the cerebellum modifies act as a comparator which compensates for errors movement have been developed from studies in in movement by comparing intention with perfor- neurophysiology and the observation of patients mance. In more detail, this is accomplished by com- with cerebellar damage. Three main functions have paring feedback signals that reflect the intended been proposed: movement (motor commands) with external feed- back signals from the sensory system that reflect the • co-ordination of the activity in all the muscles actual movement. In response, the cerebellum involved in multijoint movements modifies descending motor commands accordingly. • timing of muscle activity so that the muscle The cerebellum acts principally on the descend- groups are recruited in the correct order to ing pathways to proximal muscles that control pos- achieve the goal. ture via the muscles of the back, the neck, and the pectoral and pelvic girdles. • motor learning. Figure 12.8 shows the input of the intended Most actions involve ongoing changes in the posi- movement from the primary motor cortex, which tion of several joints moving together to produce enters the cerebellum after crossing the midline in a movement synergy. This requires the co-ordina- the pons. The sensory information from the tion of all the active muscles moving the joints. Loss vestibule of the ear and from the muscle proprio- of co-ordination is seen in patients with cerebellar ceptors, giving information about current head and damage when asked to reach out to grasp a cup. body position, enters the ipsilateral side of the cere- The movement is decomposed into separate bellum. The output from the cerebellum returns to actions at the shoulder, the elbow, and then the the motor cortex via the thalamus or relays in the wrist and fingers. red nucleus of the brain stem before entering the descending system. In cerebellar damage, patients show disruption of timing when asked to perform repetitive move- Fig. 12.8 Motor control loop between the cerebellum ments, for example rapidly pronating and supinat- and the contralateral motor cortex. ing the forearm to turn the hand over and back. Poor timing is also demonstrated by a staggering and wide-based gait. A further problem with tim- ing is seen as poor initiation and termination of movement after cerebellar damage. The role of the cerebellum in motor learning has been studied extensively in studies of animals and the theories developed have been applied to the acquisition of motor skills. An example of motor skill learning experienced by many people is learning to drive a car, when a complex sequence of movements of the upper and lower limbs is exe- cuted in relation to the activation of the handbrake, footbrakes, accelerator and clutch. After extended practice of the same sequence, the correct move- ments can be performed automatically. In the early stages, the execution of the move- ments is initiated by motor commands from the cortical motor areas with conscious awareness. It has been suggested that the motor programmes of successful movements are developed and stored in the cerebellum. After many repetitions the motor programmes can be activated without reference to the cortical areas. This means that there is a change over time to a performance without conscious

Motor Control 203 awareness. If there is any alteration in the pattern bellum. The indirect connections of the mossy of input to the cerebellum, for example a driver fibres synapse in the granule cells of the deep cell may change to a new car, then the learning process layer before sending ascending axons to the is repeated and the motor programme updated. molecular layer. In this layer each axon divides into After a short period of practice, the movements two to form the parallel fibres. They traverse the become automatic again. molecular layer of the cortex like telephone wires, and each branches to make contact with a large This theory of motor learning involving the cere- number of Purkinje cells. The arrangement of the bellum was supported by studies of the cellular parallel fibres allows for the integration of the activ- structure of the cerebellum. ity occurring at several joints simultaneously. Cellular structure of the cerebellum Sensorimotor The cerebellar cortex has layers of cells that are dis- association tributed in a uniform way over the entire surface of the cerebellum (Fig. 12.9), unlike the cerebral areas cortex where there are variations in the cell layers in different areas. The output from the cerebellum Motor is from a layer of large Purkinje cells, the axons of cor tex which end in the deep nuclei of the cerebellum and then relay to the brain stem. Two systems of incom- Basal Cerebellum ing fibres affect the activity of the Purkinje cells: ganglia the climbing fibres, which have direct connections with the Purkinje cells; and the mossy fibres, which Brain interact with cells in other layers before they stem synapse with the Purkinje cells. The climbing fibre system originates solely in a nucleus in the medulla (the inferior olive), while the mossy fibres have their origin in all other inputs to the cere- Spinal cord Muscles Fig. 12.9 Cellular structure of the cerebellar cortex Fig. 12.10 Interaction of the basal ganglia and the cere- (simplified). bellum with the cortical areas, the brain stem and the spinal cord.

204 Muscles, Nerves and Movement A model of motor learning developed in the is to descending pathways of the spinal cord to 1970s proposed that in the early stages the maintain extensor activity to keep the body Purkinje cells are excited by the climbing and the upright and provide proximal stability for skilled mossy fibres associated with a particular pattern of movements of the hands and feet. Processing of sensory feedback from the muscles, skin, eyes and visual and vestibular input stabilises the position of ears. It was shown that after many repetitions of the the head and eyes and maintains maximum visual same sequence, the direct excitation by the climb- discrimination of the environment ahead. ing fibres originating in the inferior olive was no longer required. This change with practice led to The higher centres level of control is mediated the idea that motor programmes for skilled by the primary motor cortex, interacting with sen- movements are developed with practice and sory areas in the parietal lobe and with the basal stored in the cerebellum, which became known as ganglia and the cerebellum. The basal ganglia are a ‘skills bank’. More recent studies have demon- particularly concerned with the planning of inter- strated that both the climbing and mossy fibre sys- nally cued movements. In actions that are stimu- tems are active in motor adaptation, and this leads lus driven or externally prompted, the cerebellum to the co-ordination of complex movements from compensates for errors by comparing intention with simple components, as well as providing a basis for performance. The basal ganglia and the cerebellum motor learning. There is currently a debate about exert their control via the primary motor area and the number of sites in the brain where the the brain stem motor centres, which have direct memories for motor skills may be stored. Since links to the spinal level. other components of memory, for example semantic memory, are distributed over more than The hierarchical organisation of the motor sys- one brain area, it seems likely that the cerebellum tem incorporates the modulation of activity by is not the only site for motor memories. information entering from the sensory system at each level. In Chapter 13 motor control will be Figure 12.10 shows a summary of the interaction extended to include parallel processing for the between the cerebral cortical areas, basal ganglia integration of input from the cognitive and limbic and cerebellum, the motor nuclei in the brain stem systems. and the spinal cord. SECTION III FURTHER READING SUMMARY Cohen H. (1999) Neuroscience for Rehabilitation. This chapter has considered how the motor system Lippincott, Williams & Wilkins, Philadelphia, PA. functions at three levels of control. Fisher A., Murray E. & Bundy C. (1991) Sensory The spinal level is the integration of (i) incom- Integration: Theory and Practice. F.A. Davis, ing proprioceptor activity from the muscles, ten- Philadelphia, PA. dons and joints; (ii) motor commands from the cortical motor centres via the descending system, Kingsley R.E. (1999) Concise Text of Neuroscience. and (iii) activity in local networks of interneurones Lippincott, Williams & Wilkins, Baltimore, MD. acting as basic pattern generators. The fine tuning of lower motor neurone activity at this level main- Main C.J. & Spanswick C.C. (2000) Pain Manage- tains the correct length and tension in synergistic ment – An Interdisciplinary Approach. Churchill muscles during the execution of the movement. Livingstone, Edinburgh. The brain stem level of control is based on sen- Melzack R. & Wall P.D. (1983) The Challenge of sory inputs from the eyes, the vestibule of the ear Pain. Basic Books, New York. and the muscle proprioceptors via the cerebellum. The output of integration in the brain stem nuclei Rothwell R. (1994) Control of Voluntary Movement. Chapman & Hall, London. Strong J., Unrah A.M., Wright A. & Wall P.D. (2002) Pain: A Textbook for Therapists. Churchill Livingstone, Edinburgh.

Section IV Human occupation Components and skills • Performance of functional movements • Occupational performance



13 Performance of Functional Movements Multiple factors in movement control This is not only the result of biomechanical and Emotional and cognitive factors neurological activity. The quality, speed and pre- Core positions and movement patterns cise nature of the movements produced will vary Framework for the analysis of functional according to circumstances. Hence, if the person movements has overslept and is late for work, his movements Lying, rolling and sitting up will be hurried and less well-controlled. If getting Sitting, standing and squatting up and not wanting to disturb a sleeping partner, Standing, walking and climbing stairs movements may be slow and cautious. In terms of Reaching and retrieving the physical environment, the precise performance of this functional activity will vary with the quali- This chapter will consider the production and con- ties of the bed and its relationship to the floor and trol of functional movements in the way that they other objects in the room. A soft, low bed will occur in everyday life. In human occupation, the require different qualities and degrees of move- body moves through sequences of movements. ment to get out of, compared with a high, firm bed. Each stage in the sequence involves simultaneous Such examples demonstrate the multiple factors movements at several joints and the goal for the that determine the characteristics of functional task may be reached in a variety of ways. movements. To interact effectively with the environment, the In the hierarchical model of motor control pre- body utilises a number of core positions. From sented in previous chapters, the motor commands these positions a range of movement patterns is issued at the highest levels of the central nervous carried out to move from one position to another, system drive the activity in the subcortical, brain and to orientate the body in a stable functional stem and spinal motor areas in top–down process- position for the performance of tasks. An example ing. When psychological and social factors of task is answering the doorbell, which involves rising performance are included, the motor system from sitting to standing, walking to the door and needs to be viewed functionally as a series of inter- reaching for the handle to open it. connected centres that work in series and in parallel and feature numerous feedback and feed- MULTIPLE FACTORS IN MOVEMENT forward circuits. The focus for control of movement CONTROL is thought to shift between these centres, depend- ing on the needs and demands of a given task, and The execution of functional movements is the out- the environmental conditions experienced at the come of the integration of muscular and neural time. The cognitive system is a major component components of motor control interacting with psy- of the motor control of functional movement, chological, social and environmental factors. Con- particularly when decision making and problem sider how a person gets out of bed in the morning. solving are involved. In organising and producing movement, the brain regulates posture to ensure that the body can

208 Muscles, Nerves and Movement maintain and restore equilibrium and be safe from the goal is determined by their mood at the time the threat of harm. For example, when reaching for and by their ability to organise and use stored an object, if the line of gravity begins to move knowledge about the movements involved and the beyond the base of support, compensatory adjust- environment. The ways in which emotional and ments are made to maintain equilibrium. If these cognitive factors affect functional movement will adjustments are not made, the intended goal is now be considered. abandoned as righting and saving reactions are ini- tiated. Another priority is the adoption of body Emotional factors have been shown to have a sig- positions that allow any given task to be carried out nificant effect on movement performance. Studies in the most efficient way possible. of human responses to stress have established that links exist between psychological state and physi- Consider the task of crossing one of the moving ological functioning. Neural connections between walkways found at fairgrounds. The priority in move- areas of the brain that apparently serve disparate ment is directed to the negotiation of the walkway. functions suggest the potential for psychological The attention is fully engaged in the task of keeping factors to influence motor behaviour. The reverse, upright while walking. The simultaneous execution that physical activity can influence psychological of other activities, such as talking or reading signs, state, is well accepted. The ability of physical exer- becomes impossible, whereas these would pose no cise to stimulate the release of endorphins in the difficulties when walking along a clear, level corridor. brain (neurotransmitters with some of the proper- ties of opiates) has been established, and physical To interact effectively with the environment, the practices such as relaxation and breathing exercis- body uses a number of basic, or core, positions. es are used in the treatment of some mental ill- From these positions, a sequence of movement nesses. Stress, or more specifically distress, is patterns is carried out to move from one position known to be a risk factor in the development of to another, and to orientate the body in a stable some physical conditions such as high blood pres- functional position for the performance of tasks. sure, heart disease and stroke. How then do psy- chological factors influence motor behaviour? The functional objectives guiding the selection of these positions are: In previous chapters we have seen how sensory inputs are relayed to many areas, cortical and sub- • to position the head for optimal visual and cortical, and are used to provide knowledge to an auditory monitoring of events individual in relation to the world, and to formu- late appropriate actions and behaviours. The pre- • to bring the trunk and upper limbs into the most frontal areas of the frontal lobe interact with effective and efficient position for the execution cortical areas in which meaning and significance are of tasks attached to the information received. These areas are also richly connected to the network of fibres • to ensure optimal stability and equilibrium and nuclei that form the limbic system (Fig. 13.1). • to minimise the amount of physical effort Hence connections exist that permit the attribution of emotional value to experiences, and emotional required to execute tasks and achieve goals influences upon behaviour. • to achieve human occupation The limbic system also projects fibres to the The core positions are lying, sitting, squatting and hypothalamus and is influential in determining the standing. The choice of the position to be adopted relative balance of autonomic activity within the for task performance depends on the attributes of body. Thus there are two ways in which emotion the task and the environment. An understanding of may influence motor activity. One is its contribu- the performance demands and the priorities for sta- tion at the conscious level, to decision making, bility in these positions and movements leads to the motor planning and the execution of voluntary identification of abnormalities in functional move- movements. The other is its influence upon skele- ment and the facilitation of effective performance. tal muscle tone through up- or down-regulation of central nervous system activity, depending how Emotional and cognitive factors in stressed or at ease an individual is. movement Task performance is orientated towards the achievement of a goal. A person’s ability to reach

Performance of Functional Movements 209 Fig. 13.1 Connections between the limbic system, hypothalamus and prefrontal cortex. • THINK about an occasion when you have seen a for the recognition of objects and tools. The per- friend really angry. On a piece of paper, write a list ception of the position of all the parts of the body of all the things you saw that conveyed that mood. in space, known as body scheme, is based on infor- Everything in your friend’s behaviour will be the mation from proprioceptors in the muscles and the result of muscle activity. joints. Body scheme must be integrated with visu- al and spatial perception of objects to perform the • THINK about yourself when you are happy and accurate movements of reaching and grasping. relaxed, and when you are angry. What are the dif- ferences in your speech, facial expressions, gestures Attention is another component of cognition. In and body movements between these two states? task performance, an object or a tool is grasped, and attention must first be focused on it during Cognition is a complex system of interrelated perceptual processing for recognition. Selective parts that allows people to organise and use knowl- attention allows any distracting noise in the envi- edge about themselves and the changing environ- ronment, for example people talking in the same ment to achieve goals. The output of cognitive room, to be ignored. Attention must then be sus- processing may be action, decision making or tained long enough until the task has been com- storage of information for future use. In the pleted. It is also possible to divide one’s attention, effective performance of all functional activites, for example talk to a friend while doing the task. the sensorimotor system interacts with the cognitive system. There are many components of the Memory is the stored knowledge of objects, faces, cognitive system. environmental landmarks, movements and experi- ences. When an activity is performed, motor pro- Perception is the component of cognition that grammes, stored in procedural memory, are makes sense of the environment by integrating all activated by the environment or from decision mak- the sensory input to the nervous system for mean- ing. Stored motor programmes allow people to plan ing. Visual, auditory and tactile input is processed movements and to execute the correct sequence of actions. Orientation in time is based on prospective

210 Muscles, Nerves and Movement memory of when actions must be performed in Clinical note-pad 13A: Perceptual and the future. Everyday routine actions are mostly cognitive impairments automatic, but prospective memory is required for Perceptual and cognitive deficits, which can non-routine actions that have to be remembered significantly restrict functional movement, once in a while, for example phoning a friend on her occur in many neurological conditions, especially birthday. Autobiographical memory of past experi- stroke and traumatic brain injury. The problems ences gives someone a personal identity and self- relate to the component of the cognitive system esteem. Shared experiences are important parts of that is impaired: interactions with family and friends. • attention: inactivity due to poor arousal, The highest level of cognitive processes is the distractions interrupt movement; failure to executive functions that allow people to set realis- complete a task tic goals and to modify movements and behaviour when conditions change. Tasks can be initiated and • visual and spatial perception: poor object a judgement on the performance made at the end. and/or face recognition (agnosia), under- or Executive functions are important when people over-reaching; difficulty in finding the way are confronted with an unfamiliar situation and round rooms and buildings and in the street flexible problem solving is needed to complete a task. • memory: poor orientation in time; loss of self- identity; procedural memory is usually spared. • WALK round your local supermarket selecting the items you need from the shelves. Think about • executive functions: poor motor planning and examples of all the components of perception and initiation, movement stops when a new situa- cognition that are basic to shopping: attention; tion arises; unable to judge the effectiveness visuospatial perception and body scheme; visual of functional movements. and verbal recognition; memory; executive func- tions. Evaluate the outcome when you unload the sitting up; (ii) sitting; standing and squatting; shopping at home. (iii) walking, and stair ascent and descent; and (iv) reaching retrieving. Many areas of the cerebral cortex are implicated in cognition. The visual processing in the occipital lobe Framework for the analysis of is an important part of visual perception. The pari- functional movements etal lobe processes tactile and spatial perception, body scheme and attention. The brain areas invol- A systematic approach to the analysis of move- ved in memory include the temporal lobe for recent ments enables clear identification of any limitations and spatial memory, the thalamus and hypothala- imposed by musculoskeletal, neurological and mus for procedural memory; and the frontal lobes cognitive deficits. This can form part of a broader for prospective and autobiographical memory. analysis of any task performance. The components of the functional movement analysis are as follows: Figure 13.2 outlines the serial and parallel pro- cessing between the sensorimotor, cognitive, lim- • occupational relevance and context bic and subcortical (basal ganglia and cerebellum) • description of the starting position systems for the output to the muscles in motor • breakdown of the movements into sequential behaviour. stages CORE POSITIONS AND MOVEMENT • description of any postural adjustments within PATTERNS each stage, followed by the movements of the The core positions and movement patterns that are limbs, starting proximally and moving distally. fundamental to all functional movements will now Multijoint movements are identified be considered in four sections: (i) lying, rolling and • consideration of the cognitive and emotional factors that relate to the specific movement. The ability to formulate a functional movement analysis leads to an implicit understanding of a client’s movement problems.

Performance of Functional Movements 211 Motor and Sensory system Pre-motor systems visual/auditory/ tactile/proprioceptive Sensori-motor system Cognitive Limbic association areas system system Subcortical motor Hypothalamus systems & endocrine Execution of system movement Autonomic and endocrine responses Motor behaviour Fig. 13.2 Serial and parallel processing in the sensory, motor, limbic and cognitive systems in the control of movement. Lying, rolling and sitting up the optimum starting position for sitting up from lying, when the hand of the uppermost limb Lying down is the position of rest and sleep. It is a pushes on the bed to lift the trunk to the upright position that renders the person vulnerable, as nei- position. ther vigilance nor rapid movement is easy when lying down, and is most often adopted in privacy. Rolling is a sequence of movements to change There are exceptions such as sunbathing, giving from one lying position to another. It can also be blood or receiving a massage, but in such activities a component in the process of moving from lying the person does not have to be active. Some of the to sitting and the reverse. few activities performed in the lying position that have biological and interpersonal significance are There is considerable variability between indi- those concerning sexual behaviour. viduals in the way in which rolling is performed. This can be seen by observing a group of people Lying is the most stable body position because rolling over on the floor. In changing from supine the largest possible surface area of the body is in to side lying, some initiate from the shoulders, contact with a supporting surface, the bed or the others from the legs. Some raise the arms above floor. Side lying, which allows free movement of the head during the roll. As the body rolls into the upper limb and the pectoral girdle on the prone lying, the head must be lifted by extension uppermost side, is the preferred position for of the neck to keep the face clear of the ground. reaching movements from lying. Side lying is also In all rolling movements, muscle tone is important to hold the body segments in alignment. The

212 Muscles, Nerves and Movement trunk must act as a rigid tube while the limbs are together with lateral flexion of the trunk on the side used to generate force for movement and then of the original uppermost arm, brings the head and positioned to stabilise the body. The following exer- trunk to the vertical. As the pelvis comes to the ver- cise demonstrates rolling initiated by the lower tical the legs fall into a parallel position over the limbs. side of the bed with the knees flexed and the feet on the floor (Fig. 13.3). • WORKING with a partner, one person lies on the floor, the other kneels down level with the • PRACTISE the movement sequence from side pelvis. The person lying down must first keep lying to sitting on a plinth or a bed several times. the body completely relaxed while the kneeling Stop at certain points and feel which muscles are person tries to roll him or her by lifting one side working. Refer to pushing movements of the of the pelvis. Now the supine person should shoulder in Chapter 5 and of lateral flexion of the flex one hip and knee to bring the foot flat on trunk in Chapter 10. Repeat for the return move- the floor and at the same time consciously ment from sitting to lying. increase muscle tension throughout the body. The kneeling person starts to lift the pelvis again. Note how much more easily the supine body can now be rolled. The properties of the supporting surface deter- Fig. 13.3 A movement strategy for sitting up from lying mine the effort needed. A soft, conforming surface on the side. offers limited stability and little resistance for the generation of momentum. Bedcovers may need to be considered as heavy layers hinder movement. Some people may need persuading to change from traditional sheets and blankets to a lighter duvet. The movement from lying to sitting takes the person from a position of rest to a position preparatory for activity. Without it, a person can- not commence purposeful activity or interact effectively with the environment. This movement sequence, together with moving between sitting and standing, is a prerequisite for independence in basic self-care tasks, mobility and hence all occupations. To sit up in bed, co-ordinated and simultaneous actions of the head, trunk and all four limbs are required. In moving from lying to sitting on the side of the bed prior to standing, the upper limbs drive the movement and lower limb activity varies according to how the person is lying at the start. To move from side lying to side sitting the upper- most arm pushes down on the bed to start to lift the head and trunk. With sufficient clearance, the opposite arm can be positioned to take the weight of the trunk and then push down to raise the trunk further by stabilising the pectoral girdle and extending the elbow. The momentum generated,

Performance of Functional Movements 213 Sitting, standing and squatting be done sitting, sometimes with some modification to the environment. A compromise between the two Sitting is a position from which many tasks are car- can also be achieved by the use of a high stool or ried out. Typically these tasks have one or more of perching stool, which confers the height advantage the following features. of standing with the energy conservation of sitting. • They occur in one location. • FIND three different types of chair, for example a • They require sustained attention and finely con- chair for writing at a desk, an easy chair and a stool. OBSERVE a person sitting in each of the trolled movements. chairs. Look at the vertical alignment of the head • They take long periods of time. and trunk, the tilt of the pelvis and the angle of the • They allow the line of gravity to remain within thigh with the horizontal. only one base area of support. Figure 13.4 shows three different sitting positions. In everyday life we adopt a whole range of asym- Sitting is essential to effective task accomplishment within many occupations and for the performance metric and highly variable sitting postures. These of a range of personal and social roles. Sitting and are determined by the type of chair, the relation- standing are positions that send social signals; think ship between the chair and other furniture, the of religious or civic ceremonies where the use of activities we undertake, and even the social situa- each position is clearly delineated. Sitting also cre- tion and the clothes we are wearing. The sitting ates a lap. The thighs can be used for resting and posture also sends non-verbal signals to others stabilising objects or for holding a young child safe- about our attitude, mood and degree of co-opera- ly for reading and playing. tion in a given situation or activity. By sitting a lower centre of gravity and larger base Why, then, is it necessary to think about a stan- area of support are achieved, so reducing neuro- dardised, functional sitting position? Because for logical and muscular activity for maintaining posi- any activity an effective and stable starting position tion and equilibrium, and allowing more energy and is needed, from which posture, orientation and attention to be directed to the task at hand. Many occupations traditionally carried out in standing can (a) (b) (c) Fig. 13.4 Sitting: (a) functional position; (b) low seat; (c) high stool.

214 Muscles, Nerves and Movement movement can be varied with minimal effort and most functionally effective position for any activi- optimum stability. A good sitting position allows suf- ty. The inability to stand up restricts activity and ficient movements of the trunk and the upper limbs participation in a range of environments and social for reaching and manipulating, and to bring objects situations, and can have major physical and psy- into the visual field. It is important for therapists to chological consequences. appreciate that for many people with limited mobil- ity and movement control, the sitting position may Rising from sitting involves a change from a very be their only option for engagement in daily activi- stable position, with a large base of support ties and occupations, and movement within the seat- around the legs of the chair and the feet, to a much ed position may be restricted or severely limited. less stable one, with a relatively small foot base. The centre of gravity of the body moves forwards and The orientation of the pelvis is key to the align- upwards and the line of gravity must be kept with- ment of the trunk and the head in the functional sit- in the changing base of support. Large movements ting position (Fig. 13.4a). In turn, the pelvis will be are required at the hip and knee from flexion into influenced by the angle of the femur imposed by the extension. Momentum must be generated and then characteristics of the seat and the position of the checked to prevent the body from moving forwards. feet in contact with the floor. In the sitting position Muscles that oppose the direction of movement are adopted by many for relaxation (Fig. 13.4b), or in active to operate as a brake. sitting on a high stool with no back support (Fig. 13.4c), the pelvis tilts posteriorly and the lumbar lor- • OBSERVE the movements of a subject sitting on dosis is obliterated, intervertebral discs are com- a chair as he/she rises to standing up. The move- pressed anteriorly, and strain is imposed upon the ment can be divided into four phases: (i) prepara- posterior ligaments and muscles of the vertebral col- tion: flexion of the trunk and foot placement; umn. This position also compresses the abdominal (ii) lift-off from the seat; (iii) extension; and organs, and respiratory capacity is reduced. How- (iv) stabilisation in upright standing: adjustment of ever, sitting in an easy chair for relaxation does the feet. DESCRIBE the movements of the trunk, allow for changes in position. hip, knee and ankle in each phase. Moving from sitting to standing, and the The sequence of movements shown in Figure reverse, are essential to move the body between its 13.5a–e starts with the functional sitting position, two most frequently used positions. Being able to followed by four phases in rising to standing. move between the two enables selection of the (a) (b) (c) (d) (e) Fig. 13.5 Rising from sitting to standing: (a) start position; (b) preparation; (c) lift-off; (d) extension; (e) stabilisation in standing.

Performance of Functional Movements 215 The preparation for standing phase involves foot little is written about it. Sitting down is the move- placement and flexion at the hips to bring the trunk ment for rest from standing activities. One might and head forwards (Fig. 13.5b). The most effective argue that sitting down moves the body from a less foot placement in terms of stability requires that the stable to a more stable position, and that as the feet are drawn back so that they lie close to the front movement goes with gravity rather than against it edge of the seat of the chair. The feet may be par- is less demanding. It also requires the same range allel to each other, but if forward movement is antic- of movement at the same joints as standing up. ipated immediately after rising, one foot may be What makes this movement different to most oth- placed further forward than the other. It is impor- ers is that it is done backwards. In what other daily tant for a therapist to bear in mind that such anti- actions do people deliberately execute a backward cipatory or preparatory movements, which are movement without direct visual monitoring? normally automatic, may be absent or reduced in people with movement disorders or sensory When approaching a chair, a person notes its impairments. In this phase the pelvis tilts forwards, position and dimensions, but in turning to prepare controlled by the hip extensors working eccentrically. for sitting, the chair is lost to view and they then rely upon short-term visuoperceptual memory to The lift-off phase (Fig. 13.5c) begins by dorsi- predict contact with the seat. The movement in flexion of the ankle and extension of the knee. If effect becomes open-loop because a commitment the line of gravity is not sufficiently forward at this is made to it and it cannot be adjusted once a point, lift-off cannot occur, or if attempted will fail. certain point has been passed. Remember the Initiation of lift-off is possibly triggered by tactile childish, and dangerous, trick of pulling someone’s sensation conveyed from the plantar surface of the chair away as he or she sits down. In the moments feet and proprioceptors in the lower limb. These before expected contact with the seat surface, the inform the brain that the body weight is adequately individual has committed himself to the movement within the base area of support and that weight- that shifts the line of gravity backwards and outside bearing joints and muscles are prepared for opti- the base area of support afforded by the feet, hence mal generation and control of movement. it cannot be reversed. In the extension phase (Fig. 13.5d) simultaneous, Sitting down can be likened to a form of con- forceful concentric contraction of the hip and knee trolled falling. The movement goes with gravity, extensors occurs. At the same time the trunk and so neither force nor momentum needs to be extends, thus maintaining alignment over the pelvis. generated. The extensors of the hip and the knee The plantar flexors of the ankle straighten the leg work eccentrically for the lowering of the body to and move the line of gravity over the foot base. bring the buttocks and thighs on to the seat. Once seated, the hip extensors pull the pelvis to vertical Rising progresses to the full upright posture (Fig. from its anterior tilt. The trunk is extended and an 13.5e), with appropriate adjustment of the feet for upright seated position is achieved. stability. People with weak muscles or limited joint range The speed of rising depends on the amount of in the lower limb may develop the habit of sitting momentum generated at the beginning of lift-off. down by allowing themselves to fall, especially into People who have difficulty initiating movement, or a low armchair. whose lower limb muscles are weak, compensate by using the upper limbs to provide additional lifting The design and dimensions of the chair affect the force. demands of moving between sitting and standing. A low seat increases the effort needed to initiate • TALK through with a partner the action of rising, to generate momentum and to carry the pushing down on the arms of the chair to assist body from a lower starting point up to standing. It body to rise. Refer to Chapter 5, Summary of the also increases the time taken to complete the move- shoulder and elbow in functional movements, and ment, and so decreases stability. A low seat also Figure 5.14b. increases the degree of flexion needed at the hips and knees, and dorsiflexion at the ankle, and so The ability to sit down from standing is as essen- creates difficulties for those with limited joint tial as being able to stand up, although relatively range.

216 Muscles, Nerves and Movement The movements between sitting and standing are As the hips and knees flex to lower the body, the difficult for many elderly people who experience extensors of the hip and knee work eccentrially, and some loss of muscle strength and of the range of the ankles dorsiflex. The trunk remains upright, joint mobility in the lower limb. In addition, deficits aligned over the pelvis. The movement then in visual, tactile and proprioceptive perception departs from that of sitting down because plantar reduce stability. Movement problems in getting in flexion is not initiated to move the trunk backwards. and out of chairs can have a major impact on func- Instead, the ankle continues to dorsiflex, keeping tional mobility and quality of life. the trunk centred over the feet as the centre of gravity is lowered. When maximum dorsiflexion is Squatting is a position that is rarely considered reached, the heels begin to rise off the ground and in movement texts, yet it is an important function- the trunk is tilted forwards (Fig. 13.6). al position. Young children frequently adopt this position in play activities, and adults may do so Some individuals are able to squat with the pelvis when playing with young children, or assisting them very close to the floor and the feet everted. This with personal care tasks such as dressing or drying requires great flexibility of the lower limb muscles themselves. It is also a position that some adults and joints. It is most often seen in young children may habitually adopt for specific tasks, for and in particular cultural settings. example gardening. In many cultures, elimination • STAND upright with the hands on the anterior functions are performed in squatting. In some sit- uations and circumstances, food preparation and thigh palpating the quadriceps muscle. Move other domestic tasks may be carried out on the slowly into a squat position, feeling the increase in floor. Even with modern fitted kitchens, a large muscle tension as the quadriceps works eccentri- social or family occasion may necessitate the use cally to lower the body. of floor space for food preparation. • COMPARE a high squat with a low squat position with hips adducted and abducted. Note the Compared with sitting on the floor, squatting is changes in the freedom of the upper limbs to per- a less stable position and requires more muscle form activity. work. However, the advantages of squatting as a functional position are: Fig. 13.6 Squatting. • it confers a height advantage over sitting on the floor • it allows more trunk movement and a greater reach within the position • it enables an individual to move quickly into standing. Squatting is an intermediate position that a person may move through between standing and kneeling, or standing and floor sitting. It is also a position adopted temporarily when reaching for low objects or into low cupboards. In lifting heavy objects from a low position squat- ting ensures a straight back, and enables the large muscles of the lower limbs to generate the force required for the lift. Using this position minimises strain on the back and helps to avoid serious dam- age to the spine (see Chapter 10, Fig. 10.5). The achievement of the squat position (Fig. 13.6) requires a continuation of the movement pattern needed for sitting down on a chair, but with adjust- ments to keep the line of gravity forward over the base of support, and maximal flexion at the hips and knees.

Performance of Functional Movements 217 Rising from squatting requires an initial force- aligned over one foot and then the other. The head ful contraction of the hip and knee extensors to and the trunk may be habitually aligned over one produce the upward momentum. The force need- foot in those who experience chronic pain in the ed to overcome the effects of gravity is greater than joints of the opposite leg. in rising from sitting. The standing position is affected by the features Standing, walking, and climbing up of the floor and the height of the heels of shoes. and down stairs The slope of the ground alters the position of the feet and in turn the tilting of the pelvis. High heels Standing is a more effective position for task per- tip the trunk forwards. This leads to anterior tilt- formance than sitting since the hand can be posi- ing of the pelvis and lumbar lordosis. There is more tioned over a larger area around the body. In the strain on the quadriceps muscles to keep the knee kitchen, where work surfaces are usually designed stable. Standing on rough, slippery or icy ground for the standing position, reaching can be extend- demands more muscle activity at the ankle to main- ed further by bending the trunk or standing on the tain balance. If the floor is moving, for example toes. Dressing and washing are easier when when standing in a train or bus, more muscle activ- upright, especially for the lower half of the body. ity is needed to counteract lateral sway of the trunk. Standing in a shower may be the only option for washing by those who cannot get in and out of the The upper limbs are not involved in maintaining bath. However, the base of support for the body is balance in standing, they are therefore free to per- smaller in standing than in sitting, therefore the form the movements required in functional tasks. maintenance of standing balance is a crucial fac- Standing still for long periods increases venous tor for all occupations. Many activities that are usu- pressure at the ankle, causing local oedema and ally performed standing can be adapted for the poor blood flow back to the heart. In a hot envi- sitting position, but this reduces the area available ronment this may lead to fainting. The energy for reaching and retrieving. Some jobs inevitably expenditure in standing activities is higher than sim- include long periods of standing, for example teach- ilar tasks in the sitting position, therefore fatigue ing or working in large department stores. is a factor in long periods of standing activity. Transferring loads from the standing position puts Standing is the final stage in achieving inde- less strain on the low back than sitting (see Chap- pendent mobility. Only when the body can be ter 10, Fig. 10.5). Child-care activities include trans- balanced over the feet in standing can progress ferring a baby or toddler from cot to pram, or into be made towards walking. a car seat. These can only be done from the stand- ing position. Standing is the starting position for Walking allows people to be engaged in occu- many leisure activities, for example all ball games pations where they need to move around in a and darts. In gardening, activities such as digging, variety of directions. Public areas and transport sys- mowing the lawn and cutting hedges are usually tems that are not adapted for wheelchairs remain done in the standing position. On social occasions, inaccessible for those who are unable to walk. The standing allows the interaction between a large ability to walk extends the options for work and number of people, or may be the only possibility if leisure. Walking as a leisure activity has the added the room is small. In social and work situations, an bonus of keeping joints mobile, improving cardio- individual adopting a standing position engenders vascular fitness, and experiencing the sights and feelings of command and authority. sounds of the changing seasons. Refer to Chapter 8, Fig. 8.5b to see standing Changing both speed and direction, adapting to viewed from the side. Trace the line of gravity from different surfaces and avoiding obstacles are essen- the head to the base of support provided by the tial features of functional mobility. A person must feet. The shape of the vertebral column (see Chap- be safe and free from tripping by making automatic ter 10, upright posture) forms a balanced support adjustments, especially when carrying a heavy or a for the trunk over the pelvis. In relaxed standing, delicate load. The construction worker on a the weight of the head and the trunk may be building site has very different demands in walking compared with a secretary in a carpeted office. Although a large amount of communication between people and organisations can now be done

218 Muscles, Nerves and Movement by electronic mail and computer interaction, the in contact with the ground, followed by periods of inability to walk can lead to social isolation and single support (one foot supporting the body) while depression. the other limb swings forwards to take the next step. Each individual develops a unique habitual way The sequence of movements in walking is of walking. All the measurable parameters of gait, known as the walking cycle. This is divided into such as stride length and step frequency, are relat- phases punctuated by the events of heel strike and ed to stature. If a person tries to walk in step with toe-off (Fig. 13.7a–d). someone else, it is always difficult, especially if they are not the same height. Tall people take long For convenience of description it is usual to start strides and make fewer steps per minute compared the cycle with left heel strike (Fig.13.7a). with short people walking at the same speed. Vari- ations in speed and rhythm occur with changes in The heel of the leading left leg is lowered to the mood and the time of day. The way that elderly ground at heel strike. This starts the double support people walk often reflects poor balance, reduced phase. Next, the whole foot is placed on the ground muscle strength or less sensory processing, as well by the eccentric action of the knee extensors and as cognitive factors, for example inattention and ankle dorsiflexors (Fig. 13.7b). At the same time, fear of tripping. plantar flexion of the right ankle transfers the weight on to the left leg. This is known as right toe-off. • WATCH people of all ages walking to the shops, to the station and in the park; alone and in groups. In the single support phase, the left hip and knee Notice the variety of walking speed, length of stride, extensors convert the limb into a pillar. The pelvis rate of stepping, position of the head and body, and remains level by the action of the hip abductors on amount of arm swing. the support side (see Chapter 8, Fig. 8.6). In this phase the right limb starts the swing initiated by the Walking is the progression of the body forwards hip flexors and continued by the momentum of the by repetitive movements of the lower limbs. There swinging leg. Foot clearance of the ground is are periods of double support when both feet are achieved by active dorsiflexion of the ankle and some knee flexion (Fig. 13.7c). The swinging right leg rotates the pelvis to the left. Trunk rotation in the opposite direction to the (a) (b) (c) (d) Fig. 13.7 Walking cycle: (a) left heel strike; (b) right toe-off; (c) right swing with foot clearance; (d) right heel strike.

Performance of Functional Movements 219 right keeps the head and the eyes facing forwards. In the repeated movement sequence of stair This rotation produces the natural arm swing. walking, one limb is weight bearing while the oppo- site limb is being carried through to place the foot At the end of the swing phase in the right limb, on the next step. Differences between walking and the hip extensors halt the thigh, the knee extends stepping lie in the increase in muscle strength and and the right heel is placed on the ground to start joint mobility required to propel the body upwards the next walking cycle (Fig. 13.7d). in stair ascent, and to perform controlled lowering of the body with respect to the force of gravity in It can be seen that in walking the lower limb mus- stair descent. Figure 13.8a–d shows the sequence cles work both concentrically to exert propulsive of movements in walking up one step. forces against the ground to move the body forwards and eccentrically to act as a brake to bring the move- • GO to a staircase with a partner and ask him or ment of body segments to a halt. For example, just her to walk up stairs slowly and then down stairs. after heel strike, the gluteus maximus in the lead- OBSERVE the movements in the joints of the ing leg is active to control trunk flexion and keep the lower limbs and the position of the trunk through- head and trunk aligned over the supporting limb. out the sequence of movements View from the front and from the side if possible. • OBSERVE a partner (preferably wearing shorts) as he or she walks across a large room. Stair ascent will be described starting with the Identify: heel strike, single support and toe-off in left foot already placed on step 1 (Fig. 13.8a). The one limb; and the swing phase with toe clearance right limb pushes off from the ground by plantar in the opposite limb. Note the arm movements and fexion of the ankle. The trunk flexes to bring the trunk rotation. line of gravity forwards, while the body is lifted upwards by the concentric action of the left hip and • ASK your partner to walk across the room at dif- knee extensors and the ankle dorsiflexors. ferent speeds. Does this make any difference to the time spent in support and swing? As the body moves upwards, the left limb is now in single support and the right limb starts the carry Sensory and perceptual processing increases when through (swing) phase (Fig. 13.8b). The right limb walking in a crowd or hurrying across a busy road. flexes at the hip and knee and dorsiflexes at the This is extended to higher level cognitive processing ankle. This movement continues until the right foot for topographical orientation, visuospatial memo- lies just above step 2 (Fig. 13.8c). The foot is low- ry for landmarks and flexible problem solving try- ered on to step 2 by eccentric action of the hip flex- ing to find the way in an unfamiliar environment. ors, and the trunk extends to the upright position. The right limb is now prepared for weight bearing Stair ascent and descent: the ability to negotiate and the cycle is repeated. stairs allows a person access to transport systems, shops, leisure facilities, friends and neighbours. During carry through of the right limb, the pelvis Many older public buildings and homes still have is lifted by the action of the hip abductors on the steps to the front door and to the toilets. These bar- supporting left side, and rotated to the left. riers to work and leisure lead to social isolation for those who can walk on level ground but are unsure Stair descent is described starting from step 2 in stair climbing. The problem is compounded when with the right limb stepping down first. The there is a need to carry loads, for example files and extended right limb is lowered on to the step below books, shopping or a young child, up and down stairs. by the eccentric action of the left hip and knee extensors and the plantar flexors of the ankle. The There is a wide variation in the way that people trunk is aligned over the left foot base. This con- move on stairs. Young adults may run up stairs trolled lowering of the body allows the right foot placing only the forefoot on each step. The elder- to be placed on step 1 to prepare for weight bear- ly with locomotor problems may ascend and des- ing. At foot placement, the right knee is extended, cend one step at a time, increasing the time with the hip is slightly flexed and the ankle is plantar both feet on one step to gain stability. The most flexed. The body weight is now supported by the common accident in elderly people at home is right limb and the trunk extends into the upright falling down the stairs.

220 Muscles, Nerves and Movement (a) (b) (c) (d) Fig. 13.8 Ascending stairs: (a) right toe-off, left foot placed on step 1; (b) right carry through, left support; (c) right foot clearance; (d) right foot placement on step 2. position to prepare for the lowering of the left limb rise and depth of steps, the step covering, the type on to the floor. of shoes worn and the lighting. Bifocal lenses can blur vision in stair descent. Visuospatial perception The environmental factors that influence the of the height and depth of the steps is crucial in movements to ascend and descend stairs are: the Fig. 13.9 Reaching and retrieving, variations in posture.

Performance of Functional Movements 221 ascent and descent of unfamiliar stairs. A stair rail Anticipatory movements are part of the motor allows the upper limbs to contribute to stability in planning of reaching activities. Such positioning is ascent and descent. usually performed automatically. Compensatory movements may be made during the progress of the Reaching and retrieving activity, for example the hand must remain steady when carrying a full cup of tea. Reaching and retrieving movements are key to ocupational performance. The upper limbs play a Success in reaching is dependent upon mobility at significant role in supporting, enabling and con- the shoulder joint. Without freedom of movement trolling movements of the body but in reaching and of the shoulder, only limited reaching can occur. retrieving they are the central players. Once the reach has been accomplished, the shoul- der/pectoral girdle complex must be capable of sta- This movement demands the adoption of bility and fixation to keep the hand in the desired the appropriate posture for the task being position and facilitate its functions. Retrieval move- undertaken. The degree of involvement of the ments can entail returning the arm and hand to a whole body depends on the duration, direction resting position after performing a task, or bringing and speed of movement required and the mani- an object towards the body, for example bringing pulative goal to be reached. Figure 13.9 shows three food to the mouth or putting on clothing. It is not reaching movements, each adopting different always a simple reversal of reaching, and it may form postures. an important link between one component move- ment and another in occupational performance. Table 13.1 Musculoskeletal analysis of reaching and retrieving Movement Picking up a cup with one hand to take to the mouth and drink Environment Domestic dining room. Object characteristics Standard cylindrical 150 ml cup, full of water Starting position Seated on an upright dining chair pulled up to the table Stage of movement Performance demands Reach for the cup The movement sequence can be performed within the starting base area of support. Postural adjustments are not required in the upright functional seated position. The Grasp the cup arm is relaxed, with the hand resting in the lap. The elbow flexes to lift the hand Retrieve; bring the clear of the table edge. There is simultaneous flexion at the shoulder joint and cup to the mouth extension of the elbow to reach forwards. Protraction of the pectoral girdle occurs. Task completion The humerus is maintained in medial (internal) rotation. The forearm is held in the Cognitive factors midprone position. The wrist is extended. The thumb is abducted, the fingers are abducted and extended, with slight flexion of the proximal interphalangeal joints. The cup is grasped in a cylinder grip Increase in muscle tone of all the antigravity muscles of the upper limb to bear the weight of the cup. Forearm, wrist and hand positions are stabilised while elbow flexion and shoulder extension bring the cup to the mouth. The pectoral girdle retracts. As the cup nears the mouth, small adjustments of position occur. Ulnar deviation and slight flexion at the wrist hold the cup level. Slight lateral (external) rotation of the humerus and shoulder flexion bring the cup into contact with the mouth. Pronation of the forearm tips the cup for drinking Returning the cup to the table is accomplished by reversal of the retrieval and cup-to-mouth movements. The cup is released from the grasp by extension and abduction of the fingers and thumb. Muscle tone in antigravity muscles decreases These include visuospatial perception, object recognition, body scheme related to hand-to-mouth movement, praxis associated with an open container of fluid

222 Muscles, Nerves and Movement Analysis of a reaching and retrieving task from lying requires sufficient muscle tone to keep Table 13.1 presents a musculoskeletal analysis the body segments aligned, stability in the pectoral of a reaching and retrieving movement. The and pelvic girdles, and muscle strength in the upper object characteristics and the environment deter- or lower limbs to exert pressure on the floor. Mov- mine the position and movements of the body ing to standing up requires greater strength and segments. range of movement in the lower limbs; the stabil- ity of the trunk and its alignment over the feet SUMMARY become crucial factors. Walking and climbing stairs demand the co-ordination of a repeated cycle This chapter has brought together knowledge pre- of movements when the whole body is supported sented in Sections I, II and III to formulate an by one lower limb while the other limb swings for- occupational therapy approach to the performance wards to take the next step. Few problems for of functional movement. balance are found in reaching and retrieving movements in the sitting position with its stable Motor control is now extended to include the base of support. The execution of sequences of pre- sensorimotor, cognitive and limbic systems, inter- cise and skilful movements of the hands and fingers connected in series and in parallel. The focus of to reach a goal increases the role of perception and control shifts between these centres depending on cognition. the demands of the task and the environment. The neuropsychological aspects of performance and the The reader should now feel able to apply the occupational relevance (context, goal and envi- framework for description and analysis that has ronment) to the individual of functional movement been described and used here to any purposeful patterns are considered. movement. This in turn should enable the recog- nition of movement components and skills, and The progression from lying through the core facilitate identification of component and skill positions and movement patterns to walking and deficits in the therapeutic setting. Such ability is stair climbing has been described. As one moves central to the diagnosis of occupational dysfunc- through the core positions, the demand for tion, and the remediation of identified problems in muscle strength and the range of movement at physical performance. In Chapter 14, occupation- the joints increases; new patterns of movement al performance is examined. The case histories that emerge that require a complex interplay between are presented provide opportunities for application concentric and eccentric muscle work. Sitting up of the content of this chapter.

14 Occupational Performance Framework for understanding human those occupations that you consider to have been occupation carried as a result of habit, and those that you have Role, performance, skills, components and judiciously or spontaneously decided upon. Now capacities, environment make a summary. Case histories Format for exercises • How many of your occupations were directed towards looking after yourself? PART I Example case history • How many were related to your current work? Six case histories: referral information and • Were some of them part of your leisure? related knowledge Go through your list and work out how much PART II time you spend on each category of occupation. Completion of six case histories Would the result be different if the list was made in term time compared with the weekend or People are occupational beings. From very early holiday? childhood they explore the world around them to discover the ways in which they can learn about, Compare your list with that of your friend. How manipulate, utilise and dominate their environ- similar are your lists and the categories of occu- ment. From first waking up in the morning, getting pations? Is your interpretation of work and out of bed, washing and dressing, preparing and leisure the same as that of your friend? If you were eating breakfast, communicating and responding to 10 years younger what differences would there be all surrounding stimuli; these are all occupations. in your average daily occupations? This exercise The group of Canadian occupational therapists highlights the importance of our everyday occupa- who developed the Canadian Occupational Per- tional performance, and how each person may have formance Measure (Law et al., 1998) devised an a different interpretation of their everyday occu- exercise to direct colleagues and students towards pations. For example, cooking may feel like work an understanding of the concepts of everyday occu- for one person, but pleasurable leisure to another. pational performance. This exercise suggests that Whereas a mother may enjoy and look forward to you sit down with a friend, preferably someone who bathing her baby, a carer may consider this aspect is not a fellow student. Each of you should take a of the working day as arduous. clean piece of paper and, starting in the bottom, left-hand corner, write down the time as it is at the FRAMEWORK FOR UNDERSTANDING moment. Above that write down each previous half HUMAN OCCUPATION hour until you have covered 24 hours. Next think back and list all the things you have done in the past The components that need to be considered for an 24 hours. Once you have made your list, identify understanding of the occupations of an individual are:

224 Muscles, Nerves and Movement • roles: identifies the perceived roles held by the at school or university, instructive play, cleaning individual the house, doing the ironing, etc. • Leisure occupations include visiting and social- • performance: identifies the particular perform- ising, reading, sport, travel, hobbies and crafts. ances, relating them to self-care, work and pro- ductivity, and leisure A therapist, in conversation with a client, will be able to elicit the client’s interpretation of daily occupa- • performance skills: identifies the motor and tions, a process that may assist in the understanding process skills required to perform the occupations of the particular client’s motivation and attitude towards aspects of the problems in everyday life. • components and capacities that underlie the maintenance of the occupations, including sen- Skills sorimotor, cognitive and pyschosocial aspects The level of skill required to perform occupations • environment: identifies how the individual is different between tasks. A computer operator interacts with the temporal, physical (architec- must achieve a high level of manipulative skill in tural), social and cultural environments, and operating the keyboard and the mouse. As well as their spiritual response to their present existence. manipulation, other important skills in the opera- tion of a computer would be: Role • motor skills, including positioning, stability and A person’s occupational life is closely linked to the alignment; bending, reaching and gripping roles that they fulfil in everyday living. An individ- ual may play a number of roles in one day, for exam- • process skills, including the ability to choose, ple acting as a mother, employee, carer and wife at enquire, continue, organise and terminate. different times of the day. Another example could be the roles of flatmate, friend, student, teammate The assessment of motor and process skills and lover. Behaviour and occupational lifestyle can (Fisher, 1999) can take place during performance be determined by the roles that an individual is of the client’s chosen occupation of daily living, called upon to fulfil, and these will also have an giving the therapist essential information on the effect on occupational performance. When one is impact that the client’s condition has had upon highly motivated performance may be enhanced, for their everyday life. example preparing a meal for a much-loved friend. Conversely, a task that is routine or boring may be Components and capacities performed less effectively, for example in the role of mother, doing the ironing may be a tedious task. Occupations depend on the basic processing and integration of all the information entering the nerv- Performance ous system from the world around us, which then activates the correct motor performance. Sensori- Each human occupation has a level of performance motor processing is also the basis for cognitive pro- that must be achieved in order to be effective. cessing which allows people to make decisions, to Problems caused by trauma, disease or arrested modify performance, and to recall past experience development affect performance in many different of successful outcomes. These components are: ways. The changes may present in areas of mobil- ity, manipulation, cognitive function or social • sensory awareness, sensory processing and per- interaction. Refer back to the summary of your own ceptual processing daily occupations, of which some were self-care, some work and productivity, and others leisure. • higher cortical functions of cognition and strategic planning • The daily occupations relating to self-care would include dressing, feeding, grooming, toileting, • psychosocial components related to psychological, bathing/showering and using transportation. social and self-management skills, for example, how people express their values and interests, con- • Work and productivity would include finding and duct themselves with others in a social gathering keeping a job, voluntary/unpaid work, education and manage their time during the day.

Occupational Performance 225 Environment mines the range and limitation of movement; the organisation and strength of the muscles sur- The environment has an important effect on occu- rounding the joints, and the way in which areas of pational performance. An elderly person who can the brain harmonise these muscle groups to per- function reasonably well in their own home may be form the movements that make up everyday occu- unable to be independent if he or she has to move pations. Chapter 13 analysed the core positions and to a different environment. The presence of steps, movement patterns of an individual that underpin a slippery floor or a gravel path can all interfere functional performance. with safe and confident walking. A soft chair, a low bed and the absence of adequate heating can Here, functional performance is extended into impede successful independent living. Adaptation occupation, identifying the many interactive factors of the environment may be a major factor in that may have an influence. These include: the role assisting an individual to learn to perform effec- of the individual within a family and work context, tively. The components of the environment to be personal motivation, and the motor and process considered are as follows. skills required for particular tasks. These are the factors that a therapist can assess and learn • Temporal factors, including the context of the to assemble to assist an individual to learn to client’s past, present and possibilities for the improve performance, or to take advantage of assis- future, may influence the time it takes to com- tive devices and adaptive methods of performance plete an occupation and the capacity of the client in their daily lives. to sustain effort for the period involved. Case history exercises • The physical architectural environment, that is the layout of the area and objects within it. This Six case history exercises have been devised to may vary in different situations, which may alter encourage the reader to use this book as a source the patterns and strategies needed to perform an of reference and to apply thought to the way in occupation. which a therapist might direct treatment and advice to assist a client. It is suggested that a small group • The social environment can have a marked effect of students discuss and think through each case his- on performance, for example being watched and tory and, using the framework given below, put assessed increases performance stress and may together ideas related to working with each client. interfere with normal sequencing. Format for discussion • The cultural environment plays a significant role 1. Referral information: to be read carefully, in performance, influencing the way that an occupation may be carried out and the tools and making suitable notes. equipment used. 2. Therapist’s knowledge: reference guidance for An individual’s spiritual response to each of the revision of the topics being studied. the performance components may have an effect 3. Preparation for the initial interview: roles and on the sense of the meaning and purpose of occu- pations. For example, feelings of self-esteem and important aspects of the client’s problems that personal dignity, responsibility and personal will need to be considered. courage, and other personal spiritual beliefs may 4. Therapist’s approach: be important. (i) occupational performance: self-care, work CASE HISTORIES and productivity, leisure (ii) environment and possible adaptations The first three sections of this book looked at the (iii) spiritual aspects. structure and functions of the tissues that make up 5. Comments and future management, for example: the musculoskeletal and the nervous systems, the (i) psychological effects mechanics of the joints of the body, the bony (ii) medical and surgical management architecture and ligamentous support that deter- (iii) long-term outcomes. By working in a group students will have the oppor- tunity to discuss each case history and share ideas.

226 Muscles, Nerves and Movement Each exercise will provide the referral information PART I from which the important facts can be ascertained. The relevant normal structure and function of the Part I begins with an example of a case history that systems involved should be revised from chapters has been written to demonstrate how to tackle the in the book, together with information given in the other six. clinical note-pads. A summary of the background information should be prepared in case the client EXAMPLE CASE HISTORY wants more knowledge of the condition and to equip the therapist for in-depth discussion with Information other members of the multidisciplinary team. Each client will have a personal approach to the Kathleen is a 64-year-old librarian in full-time problems that may arise as a result of disease, injury employment with the District Council Library Ser- or developmental delay, and the members of the vice. Recently, she has been feeling discomfort and discussion group may have a number of differing aching in the area of the groin and the front of her ideas. A summary of what actually occurred in each thighs, which becomes more acute as she climbs case history is presented in Part II. It will be inter- stairs. She discussed this with her husband, a retired esting for students to compare their thoughts with businessman, who said it was probably due to her this summary, it must be remembered that in the age. Her daughter, a pharmacist at the local real world the client would respond to the thera- hospital, thought otherwise and suggested that pist during conversation. The conclusions in the Kathleen talk to the family doctor. The doctor summary may be different from those reached by thought that Kathleen may have osteoarthritis and the group. However, the important part of this he arranged for her to have an X-ray at the local exercise is the process of working through the case hospital. The letter from the radiologist confirmed and preparing adequately for early conversations his suspicions, saying that Kathleen has osteoarithi- with the client. tic changes in both hip joints and some possible changes in the sacroiliac joints. Kathleen expres- Comment sed distress at this diagnosis as she had planned her The approaches and conclusions to the case histo- retirement, in 18 months time, to include active ries that are presented reflect the ideas of the grandparenting, working to renovate her garden, authors and their two advisors and do not relate to and planning visits to the National Trust houses and specific theoretical models of occupational thera- gardens. Because he realised her potential prob- py. The importance of readers’ participation in lems her doctor referred her to the community these exercises is to ensure that the biological and occupational therapist for advice and help. biomechanical significance of an impediment is considered carefully alongside the psychosocial, Therapist’s knowledge intellectual and environmental issues that may influence the healing and/or coping process. The Osteoarthritis is a process of degeneration due to Canadian Occupational Performance Measure the wear and tear on specific joints of the body. has been used to guide the reader into thinking (Refer to the hip joint in Chapter 8 and Clinical about the social, domestic and spiritual aspects of note-pad 1C.) The hip joint is the joint that trans- clients’ responses to incapacity and the way in fers the weight of the trunk, head and upper limbs which the environment can impinge upon these to the floor by means of the lower limbs. (Refer to dimensions of living. The Assessment of Motor and Chapter 13, standing and walking.) Those people Process Skills (Fisher, 1999) has been cited to alert who stand for most of their working lives are there- the reader to the complex interplay of factors that fore more prone to this problem, for example determine the way in which an activity is carried teachers, shop assistants, waitresses and librarians. out. It is hoped that the readers will find these exer- The syndrome is characterised by inflammatory cises helpful and that they allow them to consider the broader influences on clients’ health and everyday living.

Occupational Performance 227 incidents around and within the joints, and partic- Self-care ularly within the bursae surrounding the joints. Pain The therapist suggests that she might try taking her is felt in areas not related to the joint location and medication at night, instead of the morning, and in is often at its worst in the early hours of the this way she should gain the maximum benefit morning and particularly following a busy day. throughout the night. A suggestion is that Kathleen Kathleen’s interests are noted by the therapist keep a working diary for a month so that she and she expects to mention these quite early in her develops an awareness of the situations that discussion with Kathleen. may increase the discomfort. For example, is her favourite chair suitable for relaxation or should Therapist’s preparation for an initial it be higher and firmer, with better back support? interview Is her bed easy to get in and out of, is it firm enough? What effect do long periods of standing Looking at the referral, the occupational therapist or long periods of sitting have on her levels of was able to ascertain that Kathleen was married, discomfort? and from the address realised that she probably lived in an interwar, 1930s’ semidetached house Work and leisure in the suburban part of the town, quite close to At work there will be tasks that will allow her to sit shops but a long way from the town centre. As down for some of the time. Kathleen could discuss a married woman Kathleen would fulfil the her problems with her colleagues and between roles of wife, mother, grandmother (according to them they should be able to organise her contri- the referral), gardener, organiser and a member bution to the library work, making the most of her of a work team. She had worked throughout her capabilities and experience. In what ways could she life and was someone who was familiar with books tackle her gardening work most effectively? The and resource information. She would know how therapist understands that Kathleen will gain a to co-operate within a team of employees, for fuller understanding of her own condition than any example sharing the workload, working conditions, outsider, and by encouraging Kathleen to monitor holiday requests and problems relating to sickness her own progress, she may come to recognise leave. factors of cause and effect, and will therefore become more able to cope with the day-to-day Therapist’s approach management of the disease and any deterioration over time. The therapist makes an appointment to talk with Kathleen and asks her about her feelings relating Environmental adaptations to the recent diagnosis. Kathleen expresses anxiety Certainly the therapist will be able to offer ideas about her condition and how to deal with it, that have been tried in the past, such as the use of particularly the possible changes in her roles, but a kneeling stool for gardening (and even for locat- wishes to continue working until she reaches ing all sorts of objects on low shelves throughout retirement age. The therapist asks how much Kath- the kitchen and house). She may also discuss Kath- leen knows about osteoarthritis, and offers further leen’s driving experience and whether she feels able information about bursae and their assistance in to continue driving her car. An automatic car may muscle action around a joint and why they may be easier for Kathleen to drive and the therapist become inflamed in the course of the disease. The might suggest that she takes a test drive to ascer- therapist also suggests that Kathleen find a nurs- tain the advantages or otherwise of making this ing medical book in the reference library to find change. The provision of a high stool to obviate the out for herself about the hip joints and the sur- long standing periods when cooking, washing-up, rounding muscles. Kathleen has been taking the ironing or working in the greenhouse may be of new anti-inflammatory drugs, prescribed by her great assistance, and when she is visiting National doctor, but that she stills wakes up in pain in the Trust properties she should monitor how long she early morning. can cope with walking and standing before taking a rest.

228 Muscles, Nerves and Movement Future management bed was put downstairs for her. At this stage Mabel was partially weight-bearing and using a Zimmer The therapist asks Kathleen about her feelings walking frame. At the follow-up clinic 3 weeks relating to her future and the changes that will, in later Mabel was referred to the community phys- time, take place. Will she find the psychological iotherapist, and after 2 weeks of physiotherapy resources to cope with the inevitable restrictions on treatment Mabel was gaining in confidence and her life and the possibility of asking others to sup- started to work on going up stairs with a view to port her on occasions? Relating to the future, the having a bath. At this time she expressed the wish therapist will be able to give her information con- to return home but her daughter was anxious and cerning total hip replacement and its outcomes, doubtful about her ability to manage on her own. which may be needed if the pain becomes more The community occupational therapist was asked intense and intolerable. to carry out an assessment of bathing and kitchen tasks in preparation for her return to her own FURTHER CASE HISTORIES home. The next six case histories are designed for group Therapist’s knowledge discussion (see Table 14.1). The referral infor- mation about the case and an indication of the Refer to Chapter 8, the ankle joint, muscles that relevant knowledge related to the client’s condition move it and the foot. Also refer to Chapter 13, are given. Part II presents what actually occurred, reaching and retrieving, sitting to standing, walk- so that the outcome of the discussions can be ing, and going up and down stairs. compared. CASE HISTORY 2: PARKINSON’S CASE HISTORY 1: ELDERLY DISEASE PERSON Information Information Mary is a 72-year-old retired dentist who has Mabel aged 75, is a widow of some years. lived above the practice in a second-floor flat for She has a caring and supportive family of 35 years. She retired at the age of 60 and main- 10 children, all married and living nearby, tained contacts with colleagues until 12 months who see her regularly, bring in hot meals and ago. She went to see her doctor 2 years ago, as helping out with her heavier household tasks she felt stiffness in her right arm and leg and such as changing the bedding, vacuum cleaning had noticed that her handwriting was becoming and cleaning windows. Mabel has some hearing smaller. Following referral to a neurologist a impairment but is otherwise a bright, assertive, diagnosis of Parkinson’s disease was confirmed. independent person. She lives in a four-bed- At this stage a dopamine agonist was prescribed roomed terraced house, but has recently put and she coped well on this, remaining independ- her name down to be rehoused in a bungalow. She ent until 3 months ago when her muscle stiffness was admitted to hospital with fracture dislocation increased and she was aware of slurring of her of both malleoli of the right ankle and torn speech. A fall at home precipitated her admission ligaments of the left ankle. It seems that she to hospital. Mary was then sent to the local thought that she had heard the front doorbell, then neurological centre, where she was confirmed as it rang again and she jumped up quickly and fell. being medically stable and was transferred to the After 3 weeks’ postoperative hospitalisation she elderly medical rehabilitation ward, with the aim was discharged to her daughter’s home, where a being to review her medical management and rehabilitation assessment relating to her ability in independent living.

Occupational Performance 229 Table 14.1 Plan for case history discussion. DOCUMENTARY INFORMATION DISCUSSION GROUP 1. INFORMATION - 1. Discuss and make Referral and relevant details notes of the salient points relating to the client 2. Prepare a summary of the 2. KNOWLEDGE - client's condition: Revision of the specified topics - to answer questions posed from chapters, sections and by the client clinical note pads - for multidisciplinary meetings 3. PREPARATION FOR THE INITIAL INTERVIEW - Organisation of information to decide on roles of the client and significant problems which may need to be addressed 4. APPROACH - Aspects of occupational performance - Self care; work and productivity; and leisure. Environment and adaptations, and spiritual aspects 5. FUTURE MANAGEMENT - Any further medical or surgical intervention, psychological involvement and the longer term outcomes

230 Muscles, Nerves and Movement Therapist’s knowledge plex picture where the individual will display mul- tiple problems. Refer to Chapters 3 and 12, the basal ganglia, and Clinical note-pad 3G. The nature of these multiple problems in TBI may be observed in John’s occupational perform- CASE HISTORY 3: TRAUMATIC ance and this can be traced back to the underlying BRAIN INJURY performance components. John may have some or all of the performance component problems iden- tified in Clinical note-pad 3F. Information CASE HISTORY 4: HAND INJURY John aged 20 was recently involved in a road traf- Information fic accident and sustained a traumatic brain injury (TBI). John spent a few days in intensive care and Patrick, aged 47, has been referred to the occupa- then 4 weeks in an acute medical unit. He is now tional therapist following an operation to correct beginning his rehabilitation with the multidiscipli- Dupuytren’s contracture to the left little and ring nary team. Before this accident, John was inde- fingers. He has bilateral contractures and is right pendent in all aspects of his occupational lifestyle. hand dominant, but the left hand was more John appears to have multiple problems at this severely affected. At present, Patrick’s little and stage, including physical, cognitive, psychological ring fingers of the right hand are flexed to 120 and social. degrees at the metacarpophalangeal joints and the proximal interphalangeal joints, which does not The occupational therapist decides to establish interfere with his ability to obtain a power grip, but contact with John’s mother to gain more infor- is a nuisance when he is washing and dressing. mation. John’s mother explains that he currently Patrick’s left hand was first operated upon 8 years lives at home with his parents in a bungalow ago, when he gained good extension of the ring fin- along with his younger brother. John has a girl- ger but very limited extension in the three joints of friend and they were thinking about becoming the little finger. During the period since his first engaged and renting a flat in the immediate future. operation contracture of the left-hand little finger John works as a van driver delivering goods to has increased to such an extent that a second oper- shops around the city where he lives, and enjoys his ation has been necessary. Patrick works for the job because he likes driving and is interested in Water Board and in his first years was employed as cars. He also participates in sports and socialising a labourer using pneumatic drills and other vibrat- with his friends. ing tools. At this time he sometimes developed ‘white finger’ if he used the equipment for a long Therapist’s knowledge period and, because of this, he asked to be trans- ferred to lighter work. At present he works in the Refer to Chapter 3, central nervous system, the sewage branch, tending valves, hosing down areas brain and spinal cord, clinical note-pads 3B–F, and and monitoring the machinery. Patrick wishes to Chapter 13, patterns of movement in functional return to work. His wife has a part-time clerical job positions. and his children are at school, one in the lower sixth form and the other is approaching GCSE exami- TBI is usually seen as damage to brain tissue nations. Patrick is a keen snooker player; in the past caused by mechanical forces. This damage he played for his club in the local league but in may occur both at the primary site of impact recent years he has been coaching younger mem- (when he struck his head) and as the result of bers. He hopes that this second release of his left secondary complications, for example, contusions, little finger will permit him to play once more for lacerations, and the effects of shearing and rota- his club team. tional forces through the brain tissue causing diffuse axonal damage. This can result in a com-

Occupational Performance 231 Therapist’s knowledge Therapist’s knowledge Refer to Chapter 6, manipulative movements of the Refer to Chapter 3, control systems: the brain and hand, Clinical note-pad 6B, and Chapter 13, spinal cord, Clinical note-pads 4D and 11A, and reaching and retrieving. Chapter 13, lying, rolling and sitting. CASE HISTORY 5: SPINAL CORD CASE HISTORY 6: CHRONIC PAIN INJURY Information Information Susan is a 28-year-old secretary who injured her Christopher aged 40 has a 15-year history of spinal back some 10 years ago when out jogging with a cord injury. Christopher originally injured his neck friend. At that time, she was recommended to rest, in a competitive sporting accident. He spent a few take painkillers prescribed by her doctor and stay days in intensive care, where it became obvious to off work for 3 months. Christopher that he had ‘broken his neck’. He then spent 8 months at a specialist unit for individuals with Over the past 10 years increasing levels of pain spinal cord injury. During his time at the rehabilita- have impinged on her occupations and motor skills tion unit he worked every day with various members in terms of bending, walking and lifting heavy objects. of the multidisciplinary team including the occupa- Her pain originally started in the lumbar region of tional therapist to maximise his physical capacity, her back but now appears to have spread up to her adjust psychologically and rebuild his life from an neck and sometimes involves her upper and lower occupational point of view. Before his accident, limbs to some extent. Her current levels of pain affect Christopher was independent in all aspects of his all of her occupational performances with respect to occupational lifestyle. self-care on occasions. She has had frequent sick leave from work and especially from leisure activities, which Christopher is attending his annual check-up has meant that she has with-drawn from various social appointment at the spinal rehabilitation unit, pursuits. During this 10-year period she has consult- where he will see the occupational therapist as part ed her doctor and hospital specialists regarding the of this routine contact so that his occupational condition of her lumbar spine. She has been needs can be assessed and any intervention and prescribed various drugs, been given advice about management carried out. posture, taken regular exercise, worn numerous sur- gical corsets and received physiotherapy on many The occupational therapist has been in the post occasions. These treatments have worked to some for several years, and has met Christopher before, extent but have never been fully effective and she still and is aware that Christopher sustained a fracture reports the perception of pain to her doctor. of his sixth cervical vertebra during his accident and this has caused damage to the spinal segment C6/7 Susan has been married for 7 years and she and of his spinal cord. The therapist also knows that the her husband would like to start a family, however majority of individuals who sustain this damage are she is fearful that her back condition may deterio- young males who are frequently involved in acci- rate and she doubts her potential ability to cope dents on the road, at work or, as in Christopher’s with a baby. In summary, Susan feels anxious about case, occasionally playing sport. The damage sus- her future, guilty about withdrawing from various tained at the level of C6/7 implies that Christopher occupations and concerned that her life may be is functionally tetraplegic, although a large amount completely dominated by pain. of variation can be perceived in different people with the same level of injury. Through reading his Therapist’s knowledge notes the therapist remembers that Christopher has a partner, lives in a ground-floor flat, works part Refer to Chapter 11, interpretation of pain, Clini- time and drives a car. cal note-pad 11B and Chapter 13, posture in sitting.

232 Muscles, Nerves and Movement The nervous system in some individuals appears realises that Mabel’s roles are those of housewife, to change over time in response to the initial injury mother and mother-in-law, grandmother and and produce a ‘maladaptive state’. This is the result friend. of structural neuroplastic changes taking place in the nervous system created by chronic disease, in Therapist’s approach this case low back damage. The persistence of chronic pain originates in changes in the sensitiv- Self-care ity of peripheral nociceptors in the low back and Mabel can dress and carry out her own personal the transmission neurones of the adjacent area of care on a daily basis but she cannot bathe without the spinal cord, together with altered processing in assistance. the cerebral cortex. These changes in the neural pathways may outlast the original condition, Work and productivity which seems to be the problem in Susan’s case. Initially, Mabel was not keen to try a kitchen Susan’s chronic pain can still be perceived even assessment in her daughter’s home but the occu- when the tissues have healed. The peripheral pational therapist discussed a treatment plan for a and central neuroplastic changes have created written contract of achievement to be reviewed negative perceptions and led to Susan’s occupa- weekly with Mabel and her daughter, so that Mabel tional disengagement. These functional changes in could build up confidence and strength over a suit- the neural pathways may outlast the original able period. In this way her daughter would be pathological condition, which seems to be the assured of her capabilities and Mabel would have problem in Susan’s case and has created Susan’s proved to herself that she could cope. The treat- occupational disengagement. ment contract would be progressive and would include all the aspects of Mabel’s life that she PART II enjoys: This section presents what actually occurred in the • carrying out everyday kitchen tasks six case histories given in Part I. • using kitchen trolley in place of the Zimmer CASE HISTORY 1: ELDERLY walking frame when working in the kitchen and PERSON carrying things into the living room • weight-bearing going up and down stairs Refer to part I for referral information and thera- • using the bath board and seat to assist both pist’s knowledge. Mabel and her daughter in bathing. This equip- ment would, in time, be transferred to Mabel’s Therapist’s preparation for the initial home interview • practising reaching up to high and down to low cupboards to retrieve objects and put them away Mabel, who had been an independent person safely before her admission and brought up 10 children • visiting her home once a week with her daugh- in the house in which she now lives, is not finding ter and carrying out the specified tasks, first prac- it easy to be dependent on her daughter. There tised in her daughter’s home, and using the are her daughter’s husband and two grand- trolley and bath equipment in her own sur- children who also live in the house and she feels roundings. that she is a burden, and that she would like to be back in her own home where she would be Leisure familiar with everything once more. The therapist Mabel enjoys going out in the car for shopping, to a place of entertainment or to see a friend. For the first try-out of each aspect of the pro- gramme the therapist would be present, then the daughter would monitor and assist if necessary, and

Occupational Performance 233 finally Mabel would achieve things on her own. The socialise as she had done in the past. Other aspects programme progressed quickly and well, with of Mary’s illness that should be considered are Mabel regaining her confidence and the daughter potential disturbance in perceptual and cognitive feeling reassured that her mother would be able function leading to slowness in thought processes, live on her own once more. Recognising the cause inattention, and impaired motor planning and spa- of Mabel’s accident the occupational therapist tial negotiation. contacted the Deaf Society before recommending a trial stay at home for a weekend. An adapted Therapist’s approach telephone and doorbell with flashing lights were fitted, and a television amplifier. Mabel was Mary is a determined person who has read care- offered a Piper Life Line Personal Alarm but she fully about her condition and its medical man- refused. She said that she had such regular visits agement and wishes to use every opportunity from her family that this type of alarm was not to increase her functional ability. She appreciates necessary. the way in which the therapist discusses matters with her, identifies specific aspects of her problems Future management and offers solutions, and as a result she is both frank and honest about her difficulties. She The trial went successfully and Mabel moved back reports that she can use the stairs to her flat with- into her own home. Mabel had already applied for out too much difficulty and can walk quite well with rehousing in a bungalow, but bungalows as social her Zimmer frame. Her main problem is nego- housing are scarce, and once someone is rehoused tiating doorways. To overcome this the therapist in this type of accommodation they usually cope suggests that she practise walking on the spot and very well, therefore vacant ones are only infre- counting out loud before stepping forward, which quently available. It is hoped that Mabel will even- will assist in allowing her to progress through a tually move into accommodation that is on one visual barrier. level and easier to manage. Self-care CASE HISTORY 2: PARKINSON’S Following assessment in washing and dressing Mary DISEASE was found to have some problems with standing tol- erance, reduced fine finger control, limited ability Therapist’s preparation for the initial to initiate movement and, as a result of this, an interview increased level of anxiety. The therapist helps her to overcome her anxiety, and therefore the extent The occupational therapist realises that Mary will of the tremor, by adopting a more relaxed position experience difficulty in initiating and adjusting for dressing, for example sitting, choosing clothing movement, for example problems relating to mov- that is easy for her to manage and by practising ing across visual barriers, such as thresholds to breathing exercises and self-pacing. This ensures doorways and painted lines on the roadways. As a that getting dressed is tackled in a more relaxed professional person Mary will probably be able to frame of mind, so giving a greater likelihood of suc- understand her symptoms and this may cause an cess, the aim being to enhance her abilities and increase in apprehension as to her ability to over- reduce tension. Similar techniques are adopted to come them. Mary is a single, independent person, assist her with eating, drinking, swallowing and with a few close friends. The slurring of speech has speaking. Mary has also been referred to the speech a detrimental effect socially, and the reduction in and language therapist for specific treatment for her ability to react with appropriate facial expres- these aspects of her condition. sion will compound this problem and her confi- dence. Mary is likely to experience increased Work and leisure fatigue and anxiety which will impede her ability to Mary is very keen to continue cooking, writing and using her computer, all of which have been

234 Muscles, Nerves and Movement interrupted by increased tremor. After a kitchen referred to the community therapy team for assessment Mary is advised to break her activities regular monitoring and has been given an into shorter stages to avoid unnecessary fatigue. appointment to see the neurologist in 6 months’ The use of a high stool in the kitchen is suggested, time for review. as well as a trolley for moving items. However, negotiating the trolley around the kitchen and CASE HISTORY 3: TRAUMATIC other furniture proved to be more of a hindrance BRAIN INJURY than an asset and was abandoned. Advice relating to positioning for writing, and adapted pen grips Therapist’s preparation for the initial has assisted with writing and the use of a key guard interview and wrist support has meant that Mary can use her computer more effectively. Cognitive and psychosocial aspects On receipt of the referral the occupational thera- Mary reports that she is having difficulty in recall- pist remembers that a majority of individuals ing verbal information. She indicates that she finds who sustain a TBI are young males in road traffic that she cannot always concentrate and it was accidents and this is consistent with John’s profile. thought that this may be a result of apprehension The therapist is also aware that a young man and anxiety. The therapist suggests that she could like John will probably have multiple problems compensate for this problem by the use of word in relation to his injury and this will have some association and imagery. effect on his occupational performance for some time. Mary has always been a very independent per- son and so becomes easily frustrated and often Following the important conversation with his needs encouragement to focus on her positive mother it can be seen that John occupies the achievements. On an intellectual basis she was able roles of son, brother, worker, partner and to accept the effect of anxiety and low mood on friend. her performance, and is finding ways of thinking in a more constructive manner to help her to Therapist’s approach cope more effectively, and thus build up her self- confidence. The occupational therapist decides to make con- tact with John in the rehabilitation unit, where Medical management initially she finds communication with John diffi- Mary’s drug regimen has been monitored. Changes cult, as he appears slightly confused about the time, were made to the dosage in medication by moni- his location, his interests and occupational per- toring her own responses, and Mary has gained an formance up to the point of his accident. At times awareness of the relationship between taking he seems agitated and frustrated, and unable to medication and the optimal time for most efficient concentrate long enough to sustain a conversation. mobility and functioning. This understanding has His speech sounds slurred, especially when he also assisted in recognition of the periods of reports being tired. John is beginning to appreciate reduced rigidity, increased movement initiation and that he has been in a serious accident and that swallowing. he may require rehabilitation for some time. The therapist is aware that these problems will Future management have implications for John’s occupational per- formance and his relationship with his girlfriend Environmental factors and family. Mary had a home assessment before discharge from the rehabilitation ward. She feels that Self-care she has gained an improved level of mobility John is beginning to wash and dress with assistance and greater control over the symptoms that and take some interest in his appearance, although occur in Parkinson’s disease. She has been he lacks motivation regarding shaving and brush-

Occupational Performance 235 ing his teeth and requires prompting to do so. He Leisure pursuits may also require some man- is managing to control his limbs and is also agement, since John may not be motivated to beginning to express a desire to choose certain resume his interests or interact with friends, clothes rather than being passive about the or he may display inappropriate behaviour, for process. Through conversation with the therapist, example becoming uncharacteristically angry in John has expressed an interest in living independ- public. ently with his girlfriend. This will need close and detailed work with John’s girlfriend so that she Environment understands John’s problems (especially cognitive John may not require any devices within his and behavioural problems), so that realistic, home environment to assist mobility and other informed and shared progress can be made. aspects of his life, but he may have difficulties The therapist would educate both of them maintaining his environment because of lack of together through John’s occupations so that issues motivation and apathy. In order to engage mean- about motivation, understanding and concentration ingfully in his occupations he may need help would be discussed. A collaborative plan of from the therapist and his girlfriend and family to occupations that John could complete independ- structure his day. ently would be necessary, for example helping his girlfriend to prepare meals, washing the Future management dishes afterwards and being involved in planning more social interaction with friends. Other prob- John will require contact with the occupational lems that may interfere with John’s everyday life therapist for some time, especially when he goes are issues such as poor sleep patterns, staying up home and thinks about his future. Ultimately, at night and wanting to sleep during the day, fre- John’s initial physical impairments may resolve and quent headaches and the possibility John may suf- the major issues for future management might be fer a single or frequent seizures. Seizure activity centred on cognitive, behavioural and long-term may undermine John’s confidence in his abilities relationship issues. and requires compliance with medication that can have serious side-effects, especially if mixed with CASE HISTORY 4: HAND INJURY alcohol. Work and leisure Therapist’s preparation for the initial John has also informed the occupational therapist interview that he wishes to return to his job as a van driver in the city. This may be problematic, The left hand is the support hand in a right- since John is legally unfit to drive at present. handed person, but with the little finger in a flexed The Driver and Vehicle Licence Authority position this hand is unable to open out sufficiently regulations state that John would not be able to employ a power grip. If Patrick is to return to to drive for at least 6 months to 1 year, depending work he must be able to use both his hands to on the severity of his TBI. The therapist knows operate the pressure hose and to turn the that a driving centre is available at the local wheels that open and close the valves. The thera- brain injury unit and that, when appropriate, pist will carry out a functional assessment of his John could be tested formally for competence. upper limb and a sensory test to the ulnar side of If driving was ultimately ruled out the occupation- the hand, as this area of the hand can be vulnera- al therapist could liaise with John’s employer to ble to burns and other forms of injury. Work assess whether John could return to work under- will be targeted at maintaining and increasing taking a different role in dispatching goods in the extension at the metacarpophalangeal (MCP), and company stores. Another possibility would be to distal and proximal interphalangeal (DIP and PIP) suggest that John return to some form of educa- joints of the little finger, and discouraging the tion or training course so that he can learn new formation of scar nodules in the area of the skills. hypothenar eminence.

236 Muscles, Nerves and Movement Therapist’s approach CASE HISTORY 5: SPINAL CORD INJURY During the interview the occupational therapist asks Patrick to take off his coat and his shoes and Therapist’s preparation for the initial put them back on again. This allows the therapist interview to assess the function of the upper limb and the extent to which the flexed fingers of both hands Recovery of function at the level of C6/7 is variable interfere with normal dressing tasks. This exercise and observations of Christopher’s occupational may be repeated at each visit to reassess normal performance will give a clear picture of his function. The therapist also asks him about other present status. The therapist is aware that the roles coping strategies that he employs when carrying out that Christopher occupies are those of partner, everyday activities and may advise him of ways in worker, brother and friend. which mobility of the left little finger could be encouraged. Patrick will be very much involved in Therapist’s approach the initial treatment of his left hand, massaging the scar area, trying to achieve active extension and The occupational therapist makes contact with assisting the process with passive extension Christopher in the rehabilitation unit. He is a very exercises to improve occupational function of the positive outgoing individual who has worked hard to little and ring fingers. The therapist assesses the overcome the majority of his occupational per- sensation on the medial border of the hand and dis- formance problems by various means. Christopher covers that he does not have two-point dis- is sitting in his wheelchair, which he can self-propel crimination, is unable to detect hot and cold, but along flat surfaces and to some extent up small can feel deep pressure and, as this has occurred gradients without assistance. He uses ‘palm mitts’ to since the surgery, it may remain or improve. The protect the skin on his hands when propelling his therapist supplies him with a night resting splint to chair. His sitting balance in his chair is very compe- overcome undue flexion during sleep and a three- tent and he does not require thoracic supports. He point active extension orthosis to maintain and/or can operate the brakes independently, and he has increase little finger extension, while allowing active learned how to remove the chair armrests inde- flexion. (Note. It will be important for the thera- pendently, since this is required to fit his chair under pist to emphasise that gentle stretching is the way a desk. to achieve success and that the apparatus should not be used too vigorously and thereby cause tear- Self-care ing of the soft tissue. Tearing causes scar tissue to Christopher’s day starts when he wakes up in his form, which in turn will be prone to contract.) The special bed, which has an air mattress and is capa- night resting splint may be remoulded at each visit ble of turning him without assistance, so helping to to the occupational therapy department to ensure prevent the risk of pressure sores. Christopher can that the increase in extension is maintained. Once move in bed to some extent by hooking his elbow the scar has stabilised, which should take 6 weeks, into flexion through the handle of a monkey pole Patrick could return to work. He must be careful mounted above the bed. He is mostly dependent on in his observation and work practice to protect the his partner for his dressing needs, however he can ulnar side of the hand, and not to carry heavy bags wash and shave his face independently. Christopher or equipment in the left hand to avoid shearing spends a lot of the day in his wheelchair, which is damage to the skin on the medial border. Further- very important to him and is fitted with a special gel more, it would be sensible for him to continue to cushion. While sitting in his chair, Christopher man- wear the night resting splint, and practise extension ages to lift himself sufficiently to relieve pressure of the finger for 3–6 months until scar maturation from his bottom every so often, reducing the devel- is established. In relation to snooker, the left hand opment of pressure sores. In terms of self-care, the gives the bridge support and regular play should occupational therapist reinforces that prevention of reinforce a pattern of extension in the DIP and PIP skin abrasions or potential sores is of the utmost pri- joints of the left little finger.

Occupational Performance 237 ority. Christopher is relatively independent in environmental adaptations that would increase feeding and drinking. Although he finds exerting his independence. Application to the local Dis- pressure when cutting food difficult, he can man- ability Service Team, based at the Job Centre, age everything else. Insulated mugs prevent him could facilitate improvements by recommending from sustaining burn damage to his hands when government funding for the necessary work or drinking coffee or tea. equipment. Work and leisure Christopher does not have any problems relat- Christopher had worked for the same insurance ed to his leisure pursuits; occasionally he will company for many years before his accident, and research the possibility of cinemas and restaurants his employer, with assistance from the occupational being wheelchair accessible. therapist, was keen to facilitate his return to work. Christopher now works part time so that he does Environment not become unduly fatigued over the space of a Following his discharge Christopher moved into a week. The therapist reinforces the technique of new flat and therefore, before moving in, he had pacing and energy conservation whenever possible. an opportunity to modify the environment with Christopher’s current work duties include using a help and advice from the occupational therapist computer, answering the phone and talking and the builder. Christopher and his partner live directly to the public in the office. He uses a stan- on the ground floor. A small ramp was fitted at the dard computer, keyboard and monitor. He has front entrance to facilitate access. All of the learned how to use the equipment without internal doors were widened slightly to facilitate recourse to any special adaptations, by using a pen his wheelchair comfortably. All of the electrical to tap the keys. He does not want any specialised sockets were moved up from the floor to a devices or orthoses for his hands. When sitting reasonable height so that Christopher could use behind a desk, people cannot see his wheelchair them sitting in his wheelchair. The bathroom has and this is important to Christopher, since he does a special lifting device to facilitate transfers in and not want to be treated any differently from other out of the bath, and Christopher’s partner uses a staff by the public. As the office is all on the level small mobile hoist to lift Christopher onto and off and the entrance to the front door only has a slight the toilet in order to empty his bowel. A special inclination, Christopher can move freely about his inflatable rubber ring is fitted over the toilet seat work space. He uses his own car to travel to work, to prevent pressure sores. Christopher’s bladder which has been especially adapted with hand management involves the use of a sheath and leg controls for accelerating and braking, and has a bag to collect urine, which is then emptied during wrist support and handle mounted on the steering the day. wheel to facilitate turning. The car also has an auto- matic gearbox and power steering. He has a hands- Parking at home has not been a problem up until free mobile phone for emergencies. Christopher very recently, and the therapist suggests that uses a sliding board to transfer from his wheelchair Christopher might want to consider applying to the to car and vice versa. Although he is independent local council for permission to have a designated when driving, he requires assistance in terms of disabled space nearer his flat. another person folding and loading his chair into the boot of his car. His partner fulfils this One aspect that has recently revolutionised role at his home when he leaves for the office. In Christopher’s life was the purchase, assisted by the the parking area attached to his office one of his occupational therapist, of a home computer with colleagues unloads and positions his wheelchair for a grant from a charitable sporting organisation. him to transfer independently. The occupational This new computer is connected to the Internet and therapist, in discussion with Christopher, mentions this helps Christopher to exert more control over that a work site visit could be made to assess various aspects of his life. Internet shopping is par- his place of work, and that this, together with ticularly helpful, especially for food from the local liaison with his employer, could identify any further supermarket, which is delivered from the store to his kitchen. He can now pay all of his bills via the Internet and set up other banking facilities. He has also started to look for holiday accommodation in

238 Muscles, Nerves and Movement Britain that could cater for his special needs. Other never be cured of her pain in the medical sense of uses of the Internet are to research information the term and that she will need to learn to manage about rights for the disabled, products from special the effects of her pain on her occupational disability companies and the details of the Dis- lifestyle. Susan’s roles are those of wife, daughter, ability Discrimination Act. worker and friend. Future management Therapist’s approach Christopher believes that life is going well, however The occupational therapist quickly senses that from a practical and spiritual point of view he Susan is somewhat disillusioned with the health- recognises that skin problems, bladder or other care system with regard to past attempts at ‘curing’ infections could have a serious effect on his current her pain. The therapist affirms the belief that Susan and future level of independence. The therapist continues to have chronic pain despite no tissue encourages him to continue to monitor his skin damage being demonstrated on medical testing, condition, especially on his bottom, and reminds this being entirely consistent with a thorough him that he should request assistance for help with knowledge of the neural mechanisms of pain. The the maintenance or replacement of any assistive therapist explains the neural mechanisms of pain devices or adaptations when necessary. Christopher and chronic pain to Susan, so that she can appre- is aware that he should pay attention to these ciate what has happened and what will happen to aspects of everyday life and rejoice in the inde- her nervous system in the future. The principal pendence he has so far achieved. therapeutic aim is to alter Susan’s cognition and behaviour, through engagement in more occupa- Christopher’s partner works part time from tions, to create neuroplastic changes and positive home and she is the principal carer who also changes in Susan’s perceptions. Susan tells the requires support. Although Christopher is very occupational therapist that she is fearful of further independently minded, he needs to be aware that injury to her back and that she ‘holds’ herself in his partner may need assistance to manage the sit- awkward postures to prevent people banging into uation, for example some form of home help or her and causing further damage. The therapist care assistants to carry out more of the regular reassures Susan that pain is not necessarily a sign duties associated with keeping Christopher inde- of further damage or degeneration of her back and pendent in the future. that holding certain postures may make the pain worse, because of increased muscle tension. From CASE HISTORY 6: CHRONIC a spiritual perspective Susan admits being afraid of PAIN the future and does not see much chance of get- ting rid of the pain or even starting a family. This Therapist’s preparation for the initial is a difficult belief to confront. From a profession- interview al perspective, it is unlikely that Susan will ever be cured. However, if she can learn to manage the The occupational therapist is aware that Susan now effects of her pain in her life, she will regain more experiences chronic pain, as it is 10 years since the control and increased confidence. Susan will be initial tissue damage took place. The therapist also encouraged to re-engage in her occupations remembers that pain is ultimately a perception and through the use of various techniques advocated by although Susan started with low back pain, it now the Pain Society, for example self-pacing, goal set- affects her whole life, her personality and the man- ting, education about pain, learning to relax, ner in which she copes. It is important for the ther- becoming more aware of her body mechanics, pos- apist to gain an impression of Susan’s past and ture and physical reconditioning. Susan acknowl- present occupations and to gauge the degree of dis- edges that she has reduced her occupational engagement from her occupations over the past 10 engagement over the years and feels very physically years. The therapist also realises that Susan will and mentally unfit. The therapist will encourage Susan to engage in previous and new occupations

Occupational Performance 239 that will help her to recondition her muscles and monitor and other small modifications that ought improve her endurance and self-esteem. The ther- to prevent her back pain becoming worse are apist knows that when Susan feels more in control, recommended. The therapist also advises her to change will occur in her perceptions, and she may pace herself at work, by regularly changing then be more able to think about starting a her posture, standing up occasionally and learning family. to implement her newly acquired relaxation techniques. Self-care Susan does not have major self-care problems in Leisure terms of undertaking performances such as dress- Susan feels that she no longer has anything in ing, feeding and putting on make-up, however common with her social circle of friends. She she does report fatigue and exacerbation of pain now gains very little enjoyment from her leisure at times during these occupations, which means and has gradually given up running, playing that at times she cannot be bothered to do them. tennis and horse-riding, since all of these tend to On other days, she feels much better and attempts make her pain worse. The occupational therapist to do a lot to compensate fearing that she may could teach Susan relaxation techniques so that not be able to complete things the next day. In during leisure activities, she could decrease this way she is demonstrating the typical error of muscle tension and increase perceptions of the the overactivity/rest cycle, doing too much on feelings associated with comfort. She could also use good days and nothing on bad days. The therapist mental imagery to divert her cognitive processes explains about pacing performance during occu- from pain. Susan could be encouraged to apply her pations, doing less than she is capable of achieving new problem-solving skills by setting small, man- in her chosen occupations over a specified period, ageable goals, so applying self-pacing techniques irrespective of how she feels. This will mean with the aim of returning to one of her leisure that Susan will begin to engage in her self-care pursuits. occupations every day, rather than only on some days as before. This technique, energised by Environment her occupations, should improve her self-esteem This is a contentious area for the therapist. Susan and perceived success, and increase her perception has been using various devices to assist her occu- of control. Education on good and poor body pations in the past, becoming more dependent on mechanics when carrying out occupations such as devices and adaptations over time. The belief is that ironing, loading the washing machine and making overreliance on these devices reinforces negative the bed will assist in reducing muscle tension and perceptions of pain and encourages the maladap- fatigue. Similarly, Susan also has to learn to pace tive behaviours associated with pain. As Susan herself when she experiences feelings of stress in learns to manage the effects of her pain more effi- anticipation of cleaning the house, and she can ciently, she should be encouraged to give up using learn to conserve energy by pacing her own devices. involvement and by delegating certain household tasks to her husband. Future management Work To reinforce the approach of the occupational This is a difficult area for Susan since she has therapist it may be beneficial for Susan to a long record of absence from work because attend a specifically structured programme along of her pain. She feels guilty about letting people with other individuals with chronic pain. This down and, because of this patchy record, being would help Susan to appreciate that chronic pain perceived by her work colleagues as not accepting is relatively common in the population, and that responsibilities for projects at work. The occupa- individuals who have chronic pain tend to have tional therapist carries out a work site evaluation similar thought processes and exhibit maladaptive to assesses Susan’s computer work station. Various behaviours regarding pain. Staff who work on pain changes regarding her chair, the height of her

240 Muscles, Nerves and Movement management units hold common sets of beliefs and Fisher A.G. (1999) Assessment of Motor messages about pain to help people to manage and Process Skills. Three Star Press, Fort their pain. Susan would also see other people Collins, CO. improving in terms of performing more occupa- tions, and this would reinforce the perception of Grieve J. (2000) Neuropsychology for Occupational efficacy of pain management. Therapists. Blackwell Science, Oxford. CONCLUSION Hansen R.A. & Atchison B. (2000) Conditions in Occupational Therapy. Lippincott, Williams & This concludes the case history exercises. The Wilkins, Philadelphia, PA. authors hope that you have found them interest- ing and challenging and that you feel you have Law M., Baptiste S., Carswell-Opzoomer A., learned how to use the information in this book to McColl M., Polatajko H. & Pollock N. (1998) guide you in your preparation for work with future Canadian Occupational Performance Measure. clients. Slack, Thorofare. SECTION IV FURTHER READING Lovallo W (1997) Stress and Health – Biological and Psychological Interactions. Sage, Beverly Hills, Carr J. & Shepherd R. (1998) Neurological Reha- CA. bilitation: Optimising Motor Performance. But- terworth Heinemann, Oxford. Robinson S.E. & Fisher A.G. (1996) A study to examine the relationship of the Assessment Durward B.R., Baer G.D. & Rowe P.J. (1999) Func- of Motor and Process Skills (AMPS) to other tional Human Movement: Measurement and tests of cognition and function. British Journal of Analysis. Butterworth Heinemann, Oxford. Occupational Therapy, 59, 260–263. Shumway-Cook A. & Woollacott M.J. (2001) Motor Control – Theory and Practical Applica- tions. Lippincott, Williams & Wilkins, Philadel- phia, PA. Stirling J. (2002) Introducing Neuropsychology. Psychology Press, Hove.

Appendix I Bones

242 Muscles, Nerves and Movement