MOTOR RELEARNING PROGRAM
Proponents:
Janet Carr
Roberta Shepherd
Definition:
It is a task oriented approach to improving motor control, focusing on the relearning of daily
activities. . The emphasis is therefore on the analysis and training of specific tasks (such as
standing up, walking, reaching for an object), utilising information about the biomechanical
characteristics of each task, muscle function and physiology, motor learning and motor control
processes.
Theoretical base:
“Repetitive exercise and training in real-life tasks following a stroke may be a critical stimulus to
the making of new or more effective functional connections within remaining brain tissue”.
Training and practice using methods that facilitate motor learning or relearning would be
essential to the formation of new functional connections.
Clinical reasoning process which involves 4 steps:
1. The analysis of a person's performance of specific actions critical to human life -
reaching tasks,
standing up and sitting down,
walking, and
manipulative tasks.
2. Practice of missing component
3. The training of the individual in these tasks and, when necessary, in critical task components.
4. Transference of learning. Creates an environment that promotes a drive toward recovery and
relearning.
Assumption:
The authors assumed that practice of the task (or, if necessary, some component of the task) is
itself 'remedial'. In other words, practice of the action itself promotes the learning of that action,
or the learning of the muscle activation patterns (including those which we call postural
adjustments) which make up that action.
The major assumptions of Motor relearning program have been;
1. that the brain is capable of recovery;
2. that this adaption can be influenced either positively or negatively by events following
the brain lesion and by the environment surrounding the individual,
3. that a major influence on recovery is therefore the method of rehabilitation and the
environment in which it is carried out,
4. and that what the individual practices and experiences is what he or she will 'learn'.
Treatment Techniques
Strategies for instructing the Patient:
Verbal Instruction: Kept to a minimum. The therapist identifies the most important aspect
of the movement on which the patient will concentrate.
Visual Demonstration: Provided by the therapist’s performance of the task, focusing on
one or two most important components.
Manual guidance: Helps clarify the model of action by passively guiding the patient
through the path of movement or by physically constraining inappropriate components.
Feedback. Accurate, and timely feedback about the quality of performance helps the
patient learn which strategies to repeat and which ones to avoid.
Consistency of practice facilitates development of skill in task performance
Important points to consider:
Motor task are either practiced in entirely or broken down into components. The practice
of each component is immediately followed by the practice of the entire activity.
(For example: Picking up a comb or feeding)
Techniques principally comprise verbal and visual feedback and instruction and manual
guidance.
Passive movement during demonstration should not persist >1-2 times
Body alignment should be monitored consistently
Methods of Progression
Whiting (1980) has commented that ’to acquire skill does not mean to repeat and consolidate
but to invent, progress’. This means that, rather than always practising exactly the same action,
the individual should vary small details of the action.
Decrease in manual guidance and feedback
Alteration in speed
Increase in variety
Inappropriate methods of progression
Performance of motor activities in the neurodevelopmental sequence
Passive ROM exercise to resistive exercise
Parallel bars to quad cane
Wide to narrow base of support
Roll over before sitting balance
Training Guidelines
1. Sitting balance - The ability to balance in sitting while reaching for objects both within
and beyond arm's length is critical to independent living
i. Practicing simple actions that involve small shifts of the body mass initially
enables patients to regain a sense of balance and confidence that they can
move independently.
ii. Actions are practiced repetitively with no pause.
iii. Actions
a. Head and trunk Movements
- Sitting on a firm surface, hands in lap, feet and knees approximately
15 cm apart, feet on floor.
(i) Turning head and trunk to look over the shoulder, returning to
mid position and repeating to other side.
(ii) Looking up at the ceiling and returning to upright.
b. Reaching Actions
- Sitting, reaching to touch objects with the paretic hand: forward
(flexing at the hips), sideways (both sides), backward, returning to mid
position. When patient achieves a sense of balance, reaching with non-
paretic arm across body to load the paretic foot.
2. Standing balance – The exercises below include movements of the body mass ranging
from small displacements when patients are weak and apprehensive, progressing to
larger displacements performed faster.
i. Actions
a. Head and body movements
- Standing with feet a few cm apart, look up at ceiling and return to
upright.
Standing with feet a few cm apart, look up at ceiling and return to
upright (F Check
• Correct tendency to fall back by a reminder to bring hips forward (hip
extension beyond neutral) before looking up.
• Disallow foot movement. Standing with feet a few cm apart, turn
head and body mass and look behind, return to mid position, repeat to
other side.
Check
• Ensure standing alignment is preserved, with hips extended while
body rotates.
• Disallow foot movement. If necessary put your foot against patient's
foot to stop movement.
Note: Provide visual targets.
b. Reaching actions:
- Standing, reaching to take object forward, sideways (both sides),
backward.
- One hand, both hands. Variety of objects and tasks. Reaches should
be beyond arm's length, challenging the patient to extend the limit
ofstability, and return
3. Sideways walking
- Walking sideways with hand(s) on wall or a raised bed rail
- This exercise enables practice of shifting weigh from side to side with hips extended
4. Picking up objects
- Standing, lowering body mass to pick up or touch object, forward, sideways,
backward and return.
Check
• Ensure that hips, knees and ankles flex and extend.
• Start with object on stool to minimize distance to be moved
• Increase flexibility by changing base of support.
Reference:
Carr, J. H., & Shepherd, R. B. (1989). A Motor Learning Model for Stroke Rehabilitation.
Physiotherapy, 75(7), 372–380. doi:10.1016/s0031-9406(10)62588-6
Carr, J. H., & Shepherd, R. B. (2003). Stroke Rehabilitation. Guidelines for exercise and training
to Optimize Motor skill. © 2003, Elsevier Science Limited. All rights reserved.
