Sensory Motor Assessments and Interventions

MOTOR CONTROL
The ability to regulate or direct the mechanisms
essential to movement CNS
Sensory Processing
Perceptions
Tasks
Environment

Why do we study motor Control?
• Retraining movement
• Changing movement
• Improving quality and quantity of movement

Primitive Reflexes
Primitive reflexes are automatic, involuntary
movements that are essential to a baby’s survival in
the first few weeks of life.
Reflexes are quickly inhibited as higher centres of the
brain develop and voluntary responses dominant
Typical neurodevelopment shows a progressive
inhibition of the primitive reflexes and progressive
development of new skills i.e gross motor, fine motor

Why are they important?
Emerge in utero and are present at birth should be
integrated by 12 months of age (2 years at the latest)
They are the basis of our nervous system and our
abilities to move
The originate in the brain stem. This area of the brain
is responsible for survival. So if they are not
integrated then we stay in survival and stress.

Reflex Theory
When a baby is born, the higher centers of the central
nervous system – areas that allow for voluntary
movement – are not fully developed.
This means that lower areas of the brain are in control
and primitive reflexes dominate movement.
In the first few months of life, the presence of primitive
reflexes tells us that the lower portions of the central
nervous system are functioning as they should.

Reflex Theory
If primitive reflexes are absent or otherwise abnormal
(weak or asymmetrical), we may suspect neurological
injury or dysfunction in these lower areas of the
central nervous system
Reflexes are the “the way we are wired”. Help babies
eat, breathe, grasp.
Past infancy: inhibited by CNS to form foundation for
purposeful movement.

Causes of retained Primitive Reflexes
• Premature births
• Young birth mothers
• Higher incidences of alcohol/drug abuse
• Multiple births
• C-sections
• Time spent in NICU
• Lack of tummy time
• Poor awareness of developmental stages
• Neglect

When is it a problem?
If we continue to see primitive reflexes in the older
infant, we suspect that the higher centers of the brain
may not be developing normally.
Persistence of primitive reflexes can inhibit future
development, making it difficult for the baby to learn
to roll over, creep and crawl, reach and grasp, stand,
and walk

Do Primitive Reflexes disappear?
Primitive reflexes never really disappear – they
continue to “live” in the lower brain and spinal cord
and are simply masked by more mature brain
function.
This is why primitive reflexes may also be assessed in
an older child or adult with neurological disease or
injury – the reappearance of primitive reflexes may
indicate damage to higher centers of the brain.

Reflex-Hierarchical Model of Motor Control
Control of movement is Top Down.
Higher neural structures control lower neural
structures.
Limitations: Does not explain presence of normal adult
reflexes.

Hierarchical Theory
Movement is controlled by a system consisting of 3
levels with a rigid top down organization
Higher centers control lower centers via inhibition

Clinical Implications for OT
Clinical strategies designed to test reflexes should
allow therapists to predict function.
Retraining motor control for functional skills would
focus on enhancing or reducing the effect of various
reflexes during motor tasks.
When damage to CNS occurs reflexive activity re-
appears and patients have difficulty controlling them.

MORO REFLEX (startle reflex)
The Moro Reflex emerges at 9 weeks in utero and is
the earliest form of "fight or flight" (reaction to stress)
which is fully present at birth and is usually inhibited
between 3-5 months of life.
1. Over reactive
2. Hypersensitive
3. Stimulus bound
4. Difficulty with ball games

SPINAL GALLANT REFLEX:
Emerges at 20 weeks in utero, is actively present at
birth and inhibited by 3-9 months.
If fully retained, or only retained on one side may
affect posture, gait and other forms of locomotion and
is responsible for fidgeting, bedwetting, poor
concentration and short term memory, and hip
rotation to one side when walking.

SPINAL GALLANT REFLEX:
1. Inability to sit still or remain silent
2. Poor concentration
3. Continued bed wetting above the age of 5 yrs

ASYMETRICAL TONIC NECK REFLEX: (fencing)
ATNR emerges 18 weeks in utero to stimulate the
balance mechanism and increase neural connections
ATNR. It assists the birth process and is reinforced by
the birth process.
It is fully present at birth and develops eye-hand
coordination, trains one side of the body at a time and
extends ability to focus from 17 cm to arms length. It is
inhibited about 6 months of life (so that focus on
distant objects can develop

ASYMETRICAL TONIC NECK REFLEX: (fencing)
It ensures free passage of air when baby is in the prone
position and increases extensor muscle tone.
1. Handwriting: expression of ideas in written form
2. Eye tracking problems; difficulty crossing the midline

TONIC LABYRINTHINE REFLEX
TLR emerges in utero, is fully present at birth and is
inhibited by 4 months and is closely linked to the Moro
as both are vestibular in origin and activated by
movement of the head.
When retained can lead to spatial problems, motion
sickness, poor posture & muscle tone, visual perceptual
difficulties, poor sequencing skills and a poor sense of
time.

SYMETRICAL TONIC NECK REFLEX
STNR emerges at about 6-9 months of life and is
inhibited about 9-11 months. If retained affects posture,
hand•]eye coordination and swimming skills.
Also results in the tendency to slump when sitting at a
desk, ape-like walk, "clumsy child" syndrome,
difficulties with binocular vision, slowness at copying
tasks and messy eating habits.

SYMETRICAL TONIC NECK REFLEX
1. Posture lies on desk when writing
2. Poor eye hand coordination
3. Problems with refocusing from far to near distance
4. Clumsy

Neuromaturational Theory of Motor Development
Movement progresses from primitive, mass movement
reflex patterns to voluntary, controlled movement (gross
to fine).
The sequence of motor development is consistent among
infants and the rate of motor development is consistent
for each infant.

Cephalocaudal Principle of Development: The upper
portion of the body develops quicker than the lower
part of the body

Proximodistal Principle of Development: The middle
part of the body develops quicker than the outer part of
the body.

Traditional Approaches used by OT’s today
• Rood Approach
• Brunnstrom
• NDT/Bo bath Approach
• PNF

Rood’s Facilitory and inhibitory techniques
Facilitative
• Heavy joint compression
• Resistance
• Vestibular stimulation
Inhibitory
• Neutral warmth
• Slow stroking
• Rocking
• Inversion

Brunnstrom Movement Therapy
Evolution in reverse- reflexive to controlled.
Stages of Motor Recovery after CVA:
Flaccidity
Synergy- flexion then extension
Some voluntary movement
Independent movement
Isolated movement
Encourages patients to use abnormal synergy
patterns

7 stages to regain Motor Control
1. Your muscles are flaccid and you have no voluntary
movements in your affected extremities.
2. You begin to make small and abnormal movement
patterns that are not voluntary.
3. You begin to make small movements that are
voluntary but abnormal.
4. You begin to make normal movements, but most of
your movements are still abnormal.

7 stages to regain Motor Control
5. You begin to make normal and voluntary movements
that are more complex, and your abnormal
movements have diminished.
6. You begin to move your individual joints, and you
can coordinate complex reaching movements.
7. Your normal movements have completely returned.

NDT/Bobath
• Normalize muscle tone
• Inhibit primitive reflexes
• Facilitate normal postural reactions

Proprioceptive Neuromuscular Facilitation
• PNF
• Antagonist and agonist
• Diagonal Mass movement patterns
• Believes that the brain knows nothing of individual
muscle action, rather total movement patterns
• Most movements are rotational and diagonal in nature
• Typical motor development proceeds in cephalo-caudal
and proximal to distal direction
• Early motor behavior is determined by reflex activity:
mature motor behavior is supported by postural
reflexes

• The method of PNF is designed to have the maximum
resistance throughout the range of motion of primitive
patterns.
• The joint first begins at its strongest range of motion
and proceeds weaker.
• PNF incorporates mass movement patterns that are
diagonal and spiral in nature and often cross the
midline of the body.

Everyday tasks and skills, from picking up a bottle of
water to throwing and kicking naturally utilize diagonal
and spiral movements.

Systems Theory
• Describes the body as a mechanical system.
– Control of joints (flexion, extension, rotation)
– Higher levels of nervous system activate lower levels
– Muscle synergies
– Forces of gravity and inertia
– Clinical Implications: CVA

Dynamic Systems Theory Variables
• Emotional State of client
• Degree of motivation
• Cognitive awareness
• Posture/positioning
• Muscle strength and coordination
• Size, shape weight of object of interaction

Evaluation using TOA Top Down Approach

Task oriented Approach
• Different to Neuromaturation and Reflex theories
• Assumes that normal movement emerges as an
interaction among many different systems.
• Assumes that movement is organized around a
behavioral goal and is constrained by the environment.
• Adaptation to changes in the environment is critical to
recovery function.

Motor Re-learning Task-Based Rehabilitation

Guidelines from Carr and Shepherd
Assessment of motor function during task performance
Analysis of motor performance to determine key
limiting factors that are amenable to change
Prevention or reduction of limiting factors thorough
direct intervention and client education
Design of activities to be used as therapeutic challenges
that stimulate effective movement.

Intervention using Task Oriented Approach
-Client Centred focus
-Occupational-Based focus
-Person and Environment
-Practice and Feedback
-Functional goals

Which Theory is Best?
• No theory has it all
• Therapist must combine relevant elements from all
theories.
• Evolved into dynamic systems approach to intervention:
– Individual (perception, cognition, action)
– Task
– Environment
In Occupational Therapy, intervention strategies should
be grounded on a theoretical framework that provides a
rationale for therapeutic strategies.
Many clinical interventions can be substantiated by either
the neuromaturational or systems theoretical models.

Key Points
• Neuromaturational approaches provide foundation for
clear understanding of CNS and motor skill development
• Systems approaches emphasize consideration of
parameters outside of CNS.
• Therapists must understand and use both models to
develop effective intervention.

Sensory Motor Assessments and Interventions

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