54th Annual National Conference of
The Indian Association of Physiotherapists
WORKSHOP ON “MOTOR RELEARNING PROGRAM FOR STROKE REHABILITATION “…..A Practical Approach
On 17th and 18th February 2016
Dr. Gajanan Bhalerao (PT)
Master of Physiotherapy (Neurosciences)
Sancheti Institute College of Physiotherapy
Motor Relearning Program in Stroke Rehab click here for link
Registration from click here registration_form
Carr & Shepherd, Australian physical therapist, among a growing group of physical therapists (Duncan & Lai, 1997; Lister 1991), occupational therapist (Mathiowetz& Bass Haugen, 1994;trombly & Wu, 1999) & movement scientist (Gentile, 1998; Shumway – cook & Wolcott, 1995) who apply principles of motor learning to practical rehabilitation intervention for people with motor difficulties due to CNS dysfunction.
Clients who demonstrate potential to improve motor control decrease the opportunity to learn to perform motor task with efficiency, fluidity & versatility.
MRP provides with practical guidelines for the following:
- Assessment of motor function during task performance
- Analysis of motor performance to determine key limiting factors that are amenable to change through therapeutic intervention
- Prevention or reduction of these key-limiting factors through direct intervention and client education.
- Design of to be used as therapeutic challenges that stimulate development of effective movement strategies
- Adaptation of the physical environment to promote maximum function by each individual.
- Assistance for individual in developing strategies for approaching & mastering the motor challenges of new activities they may wish to perform in the future.
The framework on which Carr & Shephered’s approaches is based includes the dynamical systems theory of motor control, the plasticity of the CNS, & the maladaptive biomechanical changes that occurs after CNS injury. Principles of motor learning guide the therapist in structuring the therapeutic environment to maximize patients recovery of motor function.
Dynamic system theory & CNS plasticity
A principle of dynamic system theory, is that organism demonstrate an inherent capacity to self organize throughout life (Perry, 1998). Plasticity (Kolb,1195) is a capacity to reorganize after disruption & to adapt to functional demands. Although a damaged tissue does not structurally regenerate, plasticity in the mammalian CNS has been well documented. Carr & shepherd assume that therapeutic challenges have the potential to influence how a persons neuromuscular system will reorganize itself after injury to the CNS. Furthermore they recognized that those voluntary movements are initiated by functional task goals (Jeannerod, 1990; Willingham, 1995) and are influenced by the special and force characteristics of the objects (Mathiowetz& Wade1995; Trobly&Wu, 1999). Therefore, functional task demands are used instead of exercises to provide graded motor challenges.
Our understanding of motor behavior – motor control, motor development & motor learning – continues to evolve (Van Sant, 1991). Sophisticated technology has led to an explosion of information about the control, development, & acquisition of movement (Lister 1991). Human movement scientists, neurophysiologists, impose order of the many pieces of information; they deduce models & theories of motor behavior. As these models & theories change, a therapeutic approach also has changed.
As a result of changes in the motor behavior literature, some (eg. Gordan,1987; Shumway –Cook & Woolacott,1995) have questioned the assumptions underlying the neurophysiological approaches, which include Rood’s (1954) sensory motor approach, Knott & Voss (1968) proprioceptive neuromuscular facilitation, Brunnstrom’s (1970) movement therapy, &Bobath’s (1978,1990) neuro developmental treatment . Two tasks –related approaches, a task – oriented approach (Horak, 1991; Mathiowetz& Bass Haugen 1994) and Carr & Shepherd’s (1987) motor learning program approach are being proposed as alternative to the neurophysiological approaches. The assumptions of these new approaches are derived from a systems model of motor control, system theories of motor development, & recent motor learning theories.
This course is a guide to treatment planning for stroke patients written by two well respected physical therapists from Australia. The Motor Relearning Programme (MRP) treatment model is gaining popularity among physical therapists in this country. The model focuses on eliciting specific motor responses through everyday activities, a shift away from the traditional physical therapy model of exercise and movement. The MRP involves the training of muscle activity, functional movement of the affected limbs, and prevention of compensatory activity by either the affected or the intact side. For decades, occupational therapists have been working with the functional movement of involved extremities; however, this model presents some innovative ideas that challenge widely accepted therapeutic techniques used to treat stroke patients, such as stimulation of mass movement patterns, use of resistive exercises, and use of the intact side to assist the affected side.
The MRP is based on four elements: the elimination of unwanted motor activity, feedback, practice, and the relationship between postural adjustment and movement. The program is made up of seven sections comprising what the authors feel are the essential motor functions of everyday life: upper limb function, orofacial function, sitting up over the side of the bed, balanced sitting, standing up and sitting down, balanced standing, and walking. A description of the normal function, along with its essential components, precedes each program. The learning of each function is broken down into four steps: analyzing the task, practicing missing components, practicing the task, and transferring the learning into everyday activities. Specific problems, such as difficulty with swallowing, are addressed. Techniques of manual guidance and cuing are explained and illustrated. Common therapists’ errors and patients’ compensatory strategies are outlined as checkpoints. The presentation of each function concludes with a discussion of the transference of training into daily life. Of particular interest in the chapter on upper limb function is a brief analysis of the painful shoulder. References, which provide valuable information for further inquiry, follow each chapter. Appendixes outline the factors that are essential for motor training. Theoretical mechanisms, including neural adaptations by which recovery can take place, are presented.
A full description of the development of the MRP is included, as are guidelines for establishing the most beneficial environment for recovery and learning. The authors make the assumption that people with disabilities have the same learning needs as nondisabled people. The program deals primarily with motor problems; it does not deal with cognitive or perceptual dysfunctions. There arc some practical guidelines for dealing with outbursts of weeping and problems of incontinence. This course is well organized and provides concrete suggestions for dealing with the specific motor problems associated with strokes.
After the course the participants are expected to be able:
- Name the essential components (invariant kinematic features) of seven activities of daily living, supine to sit, sitting balance, sit to stand and stand to sit, standing balance, walking, upper limb function of reaching and manipulation and oro-motor control.
- Recognise common compensations when observing people with stroke/brain injury attempting these different activities of daily living; understand and explain why these compensatory strategies should be discouraged during practice.
- Discuss factors thought to contribute to the development of muscle overactivity /spasticity, and strategies to prevent these secondary problems.
- Explain the relationship and differences between spasticity / overactivity, muscle length changes, missing essential components and compensations.
- Plan and conduct an observational analysis and motor training session with a person who has had a stroke.
- Name key factors that affect motor learning, and how these factors can be modified to enhance learning and increase intensity of practice.
- Apply the principals of motor learning and essential component in training the skills in activities of daily living
Day 1:Theory and models of practice and skill training in Motor Relearning Program in stroke rehabilitation: Training of supine to sitting and standing balance.
Day 2:Theory and models of practice and skill training in Motor Relearning Program in stroke rehabilitation: upper limb control training, Gait training, oromotor training, management of complications.
Target Audience:The workshop will be of interest to occupational therapists and physiotherapists from hospital and community based settings, who teach adults following stroke and acquired brain impairment, as well as university lecturers and finalyear students of Bachelor of physiotherapy or occupational therapist or interns. Therapy assistants can attend the workshop. (Assistants have found the course relevant and useful if they are responsible for helping with coaching and training patients). Therapists working with people affected by traumatic brain injury and other neurological conditions will find the workshop relevant. However, most of the examples provided and stroke participants attending are likely to have had a stroke. Therapists working in paediatric neurology may also find the workshop helpful however, all the examples used will be adult populations.
Course Length:2 days
Credit hours – 14
|1.||INTRODUCTION||9.0010.00am am||Theory lecture||Dr. Gajanan|
|What is importance of the task specific approach? (Carry over, Neuroplasticity)|
|General Assessment of stroke & common problems|
|2.||MRP Assessment||10.00am- 11.00am||Practical demonstration on models||Dr. Gajanan .|
|Step 1||Analysis of task|
|Step 2||Practice of missing component|
|Step 3||Practice of task|
|Step 4||Transfer of training|
|3.||GUIDELINES & STEPS FOLLOWED||11.00am 1.00pm||Practical demonstration on models||Dr. Gajanan .|
|3a||Training of Supine to sit|
|3.1||Training of Sitting Balance
|3.2||Training of Upper Limb control
|3b||Application of four steps of assessment and Training for supine to sit, sitting balance and upper limb on patients.||2.00- 5.00pm||Assessment & Treatment demonstration on patients||Dr. Gajanan.|
|QUESTIONS & FEEDBACK|
|3.3||Training Of Standing Up & Sitting Down||9.00am-11.00pm||Practical demonstration on models||Dr. Gajanan|
|3.4||Training Of Standing Balance|
|3.5||Gait Training Orthotic prescription
|3c||Application of four steps of assessment andTraining for sit to stand, standing balance and gait training on patients.||11.am-1.00pm||Assessment & Treatment demonstration on patients||Dr. Gajanan .|
|3.6||Gait training &Oromotortrainng||2.00-3.00pm||Demonstration on patients||Dr. Gajanan|
|4||Complications and its management||3.00-4.00pm||Lecture & discussion||Dr. Gajanan|
|4a||Shoulder hand syndrome|
|5||Evidences of motor relearning program|
|QUESTIONS & FEEDBACK||4.00-5.00pm||Dr. Gajanan .|
The workshop focuses on practical demonstration & handling techniques in the Neuro rehabilitation. The workshop also aims at enhancing the skills of the participants & better understanding of problems commonly encountered in the management of stroke patients. Besides the workshop will emphasis on insight into unique case studies as well.
- A Motor Relearning Programme for Stroke (2nd cd.) Janet H. Carr and Roberta B. Shepherd (1987). Aspen Publishers, Inc., 1600 Research Boule· vard, Rockville, MD 20850.
- GajananBhalerao, VivekKulkarni. Comparison of Motor Relearning Program and Bobath Approach in acute stroke rehabilitation. Indian journal of orthopedic and rehabilitation. Vol 1. 2010.
- GajananBhalerao, VivekKulkarni. Comparison of motor relearning program versus Bobath approach at every two weeks interval for improving activities of daily living and ambulation in Acute stroke rehabilitation.International Journal of Basic and Applied Medical Sciences. 2013 Vol. 3 (3) September-December, pp.70-77
- GajananBhalerao, ShanitaFernandes, RachanaDabadghav, NilimaBedekar, Ashok Shyam, ParagSancheti. Current practice and concept of voluntary control and its clinical application among physical therapist. Accepted for publication in Indian Journal of occupational & Physical Therapy.
- Hsieh CL, Sheu CF, Hsueh IP, Wang CH. Trunkcontrol as an early predictor of comprehensiveactivities of daily living function in stroke patients.Stroke 2002; 33: 2626-30.
- Nichols DS, Miller L, Colby LA, Pease WS. Sittingbalance: Its relation to function in individualswithhemiparesis. Arch Phys Med Rehabil 1996; 77: 865-69.
- Partridge CJ. Neurological physiothercapy: aproblem -solving aipproach. Churchill Livingstone,1996.
- Carr JH, Shepherd RB. A motor relearningprogramme for stroke. Butterworth –HeinemannPhysiotherapy, 1987.
- Pollock AS, Baer G, Pomeroy V, Langhorne P.Physiotherapy treatment approaches for therecovery of postural control and lower limbfunction following stroke. Cochraine Database ofSystematic Reviewvs 2003; 2: CD001920.
- Dean CM, Shepherd RB. Task-related trainingimproves performance of seated reaching tasks afterstroke: A randomized controlled trial. Stroke 1997;28: 722-28.
- Dean CM, Richards CL, Malouin F Task-relatedcircuit training improves performance of locomotortasks in chronic stroke: A randomized controlledpilot trial. Arch Phys Med Rehabil 2000; 81: 409-17.
- Langhammer B, Stranghelle JK. Bobath or MotorRelearning Programme? A comparison of twodifferent approaches of physiotherapy in strokerehabilitation: A randomized controlled study. ClinRehabil 2000; 14: 361-69.
- Wellmon R, Newton RA. An examination ofchanges in gait and standing symmetry associatedwith the practice of weight shifting tasks. NeurolRep 1997; 21: 54- 55.
- Sabari JS. Motor learning concepts applied toactivity-based intervention for adults withhemiplegia. Am J OccupTher 1990; 45: 523-30.
- Chan CCH, Lee TMC, Fong KNK, Lee C, Wong V.Cognitive profile for Chinese patient with stroke.Brain Injury 2002; 16: 873-84.
- Chan YL. Efficacy of motor relearning program inimproving function after stroke. Master’sDissertation, The Hong Kong PolytechnicUniversity, 2000.
- Berg KO. Balance and its measure in the elderly: Areview. Physiother Can 1989; 41: 240-46.
- Podsiadlo D, Richardson S. The timed ‘up andgo’: a test of basic functional mobility forfrail elderly persons. JAmGericatrSoc 1991; 39:142-48.
- Hughes C, Osman C, Woods AK. Relationshipamong performance on stair, ambulation,functional reach, and timed up and go tests in olderadults. Issues Aging 1998;
About Resource person
|Dr. GajananBhalerao (PT):|
|· Qualification: Master of Physiotherapy (Neurosciences) C/NDT
· Advanced Certified NDT practitioner course from NDTA (USA) in 2014; Registered NDTA member -80596
· Clinical experience: Stroke and brain injury rehabilitation for 12 years in India
· Academic experience of 9 years of under graduate and post graduate teaching experience atSanchetiphysiotherapy college in Pune.
· HOD &Associate professor in Physiotherapy therapy at the Sancheti college of physiotherapy Pune India
· Head of department of physiotherapy and rehabilitation, Sancheti hospital Punesince 3 years.
· Post graduateguide since last 5 years atSanchetiphysiotherapy college in Pune.
· Resource person for workshopson neuro therapeutic approaches (Bobath, PNF, MRP, SCI rehab, NDT) and Gait analysis and management since 8 years.
· Private Physiotherapy therapy practitioner offering community-based motor retraining for people with stroke, brain injury, spinal cord injury and balance disorders.
· Certified training in Basic and Advance research methodology organized by Phd research cell of Maharashtra university of health sciences Nashik at Pune &Nashik
· Certified training in Basic and Advance Medical education teaching technology organized by Maharashtra university of health sciences Nashik at medical education technology (MET) cell Pune.
· Certified training manuscript writing, grant writing for research and publication organized by Maharashtra University of health sciences Nashik at medical education technology (MET) cell Pune.
· Have private clinic “GB Neurophysio center, at JM road of Pune city.
· Research and publications: published paper on Motor relearning program VsBobath approach in stroke rehab, cerebral palsy. Ongoing research on effect of shoe raise along with MRP in chronic stroke rehab on ambulation. Therapist perspective about neuro approaches & Stroke rehab.
· Doing PhD in physiotherapy on clinical gait analysis method from School of physiotherapy & KEM hospital Mumbai, India