(1)
Neurorehabilitation Centre at CNA, Breda, Noord-Brabant, The Netherlands
Summary
By looking at motor problems from several angles, it is possible to establish a treatment strategy with which you think you can achieve the best result. It is then a case of assessing whether that strategy also fits the patient and his immediate surroundings. If so, then every legitimate strategy that contributes to the independence of the patient is the optimal treatment strategy. Application of the models described in this chapter can contribute to formulating a multidisciplinary treatment strategy. The intention is not to describe them in detail. The aim is to make the models transparent by means of examples from practice. Thereafter, it is important to determine which learning strategy is the best match to the patient with a CNS disorder.
9.1 Introduction
Knowledge of the different motor models contributes to the ability to interpret the observed motor skills. They provide an explanation or hypothesis for why someone moves or acts in the manner that he shows. What follows is a description of a number of motor control models. It is not the intention to describe them in detail. The aim is to make the models transparent by means of examples from practice.
9.2 Hierarchical Model
Insight into the hierarchical model is relevant, because it has been a determining factor for a number of decades when it comes to deciding what should be included in treatment plans with respect to patients with a CNS disorder. The hierarchical model, on which the NDT concept was based, assumes that the higher parts of the brain control the lower parts. The consequence of a lesion in the higher functions is reduced control at the underlying levels. Primitive reflexes, according to this model, then gain the upper hand when there is damage in the cortex. When there is disruption at the paleo level (◘ Fig. 9.1), for example, problems can arise in the spontaneous motor system, as in Parkinson’s disease.
Fig. 9.1
Hierarchical model
In this model, the occurrence of impaired self-righting reactions, primitive reflexes, and spasticity is explained from a hierarchical classification of the brain. The therapeutic interventions were matched in the last few decades to this presumed classification of the brain. Attempts were made to inhibit the muscle tone by means of manual interventions, and then efforts were made to regain normal motor skills. Empirical studies have since then made clear that the muscle-tone normalization achieved had no structural effects. Short-lasting muscle-tone normalization can however be the goal of an intervention, for example, when making a transfer or when the personal care of the patient is impeded by spasticity.
Example from Practice 9.1
Mr. P. has MS and experiences problems with getting out of bed because of the severe spasticity in both legs. He has been advised, before he makes the transfer, to move from lying on his back to lying on his side, to put his arms in the air first, and at the same time to move from left to right. This causes rotations in the trunk and by doing this the spasticity in the legs is inhibited. Once he is sitting on the edge of the bed, he has to put both feet firmly on the ground and slowly, by means of moving the weight repeatedly sideward and, then from the front to the back, put pressure on the feet. This facilitates the support function; as a result of this, it is easier for him to stand up.
This transfer gives him a lot of problems, especially if he has been sitting for a long time and if he has to make the transfer in a busy room.
Example from Practice 9.1 describes a hierarchical approach to a case. Previously it was assumed that structural changes would take place in respect of the spasticity. For this reason, the transfers were offered in this way, and there was not much freedom to deviate from that. In the meantime, it has been shown that there are no structural effects on the muscle-tone dysregulation through this approach.
Other approaches are, therefore, supplementary, because any manner of increasing the independence of the patient is welcomed. In the next example from practice, the same case is considered from a different motor model.
9.3 Heterarchical Model
The heterarchical explanation model assumes that the brain is an information-processing system that is in contact with its surroundings. Upper and lower parts work alongside and not in an upper/lower relationship. Within the context of this book, this means that spasticity is not only the consequence of the disappearance of the controlling function of the upper parts; it means that spasticity is also influenced by the information processing that has to take place. The degree of spasticity can be higher if someone is walking in a busy street, for example, and therefore all sorts of things around the person have to be perceived. In his trusted surroundings, this is not the case and the spasticity will be present but will be diminished.
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