Motor Skill Training in Spinal Cord Injury

Original Editor - Habibu Salisu Badamasi

Top Contributors - Naomi O'Reilly, Kim Jackson and Habibu Salisu Badamasi

Introduction[edit | edit source]

Spinal cord injury recovery heavily relies on retraining muscles through repetition. motor skill acquisition occur through mass repetition of optimal movement patterns when patient is unable to initiate due to sensation,cognition or coordination.[1] A primary strategy for the rehabilitation of sensorimotor impairments and related disabilities is to put patients in a position to be able to practice and continuously improve upon their motor control and skills.[2] Functional independence is one of the primary goals for people with SCI.A key component of gaining functional independence is learning how to perform motor tasks following SCI. patient with SCI usually present with different motor impairments,causing an important limitation in the performance of activities of daily living.[3]

Principles of Effective Motor Skill Training[edit | edit source]

People with a spinal cord injury may be unable to perform some motor tasks because they:

  • Have impaired dexterity as a direct consequence of their spinal cord injury
  • Lack the skill required to perform new tasks

Lack of Dexterity[edit | edit source]

Dexterity refers to the ability to coordinate muscle activity to suit the demands of the task and environment.Impaired dexterity may occur as a direct result of the spinal cord injury. For example, people with incomplete tetraplegia may have sufficient strength but insufficient dexterity to manipulate objects with the hand.[4]

Lack of Skill[edit | edit source]

People with spinal cord injury often lack the skill required to perform motor tasks. This is because many of the motor tasks required for functional independence following spinal cord injury are novel and must be learnt. For example, a person with paraplegia needs to learn to transfer from the wheelchair and carry out skill such as a wheel stand (wheelie).[4]

Task-oriented skilled training improves patients motivation and which in turn, may improve the ultimate rehabilitation outcome, that is, participation in the community[5]

Assessment of Motor Tasks[edit | edit source]

Performance of motor tasks can be assessed in many ways such as using:

  1. Generic measures of activity and participation, eg. The Functional Independence Measure
  2. Spinal specific measures of activity and participation, eg. The Spinal Cord Independence Measure.
  3. Tools that assess single motor tasks, eg, The Walking Index for Spinal Cord Injury
  4. Simple measurement tools, e.g. A stop watch to measure 10m walk or a tape measure to determine height of a lift

Motor Training[edit | edit source]

Motor training for people with SCI requires the physiotherapist to have a good understanding of the optimal levels of motor function that people can expect to attain and the common ways people with different levels of SCI perform motor tasks.

The common ways of performing each motor task are best described in terms of sub-tasks.Sub-tasks are the critical steps required for successful performance of a task. Each motor task contains a series of sub-tasks or key steps.[6]

Moving from Lying to Sitting[edit | edit source]

The ability to independently move from lying to sitting is important for dressing and moving about the bed.[6]

Lifting or Leaning for Pressure Relief while seated[edit | edit source]

The ability to lift or lean the body while seated in a wheelchair is an important skill to master as soon as possible after SCI for the prevention of pressure ulcers.[6]

Transfers from the Wheelchair to the bed[edit | edit source]

The ability to move between the wheelchair and the bed, car, toilet, floor and is a fundamental to a person's Independence[6]

Transfers from Floor to Wheelchair[edit | edit source]

moving from the floor to the wheelchair is a useful motor skill to master because people periodically fall out of their wheelchairs or need to get up off the ground for other reasons[6]

Mobilising in a Wheelchair[edit | edit source]

Moving about in a wheelchair requires many different skills regardless of whether people are mobilizing in manual or power wheelchairs.[6]

To function independently, manual wheelchair users must have a variety of wheelchair skills that enable them to deal with the physical barriers they will inevitably encounter in various environments. Mastering wheelchair skills can mean the difference between dependence and independence in daily life; therefore, training of these skills is a vital part of the rehabilitation process.[7] The Wheelchair Circuit is a test to assess manual wheelchair skill performance. It consists of 8 different standardized tasks that were performed in a fixed sequence on a hard and a smooth floor surface and on a motor-driven treadmill. The 8 tasks are figure-of-8 shape,crossing a doorstep (height, 04m ),mounting a platform (height,10m),15m sprint,3% slope,6% slope,3-minute wheelchair propulsion, and transfer.[7]

Walking[edit | edit source]

Walking is feasible primarily for individual with at least some strength in the lower limbs.Improvement of locomotor function is one of the primary goals for people with SCI. Locomotor training for walking is therefore used in rehabilitation after SCI and might help to improve a person's ability to walk.[8]

Standing[edit | edit source]

All individual with SCI can stand, provided they have appropriate equipment.


[9]

Virtual Reality Interventions[edit | edit source]

Virtual reality interventions showed positive effect on motor function by significantly improving the upper limbs motor function, range of motion, functional tasks, grasp, and pinch forces.[3]

Motor Learning Theory[edit | edit source]

Motor learning emphasize the importance of skill training at the activity level according to international classification of functions (ICF).[10]

Motor training is based on motor learning theory.It is most effective when:[4]

  • It incorporates a large amount of practice
  • The tasks are practiced in the context they will be performed
  • Sub-tasks are practiced if the whole task is too difficult
  • Manual guidance is used appropriately
  • Sub-tasks or tasks are progressively made more difficult
  • Appropriate instructions and/or demonstrations are used
  • Feedback is appropriate

[11]


Motor task training is most effective when it incorporates a large amount of practice.[edit | edit source]

Practice is essential when learning new motor tasks. Ideally practice should be intensive, well structured, designed to maintain motivation and occur inside and outside of therapy times.Strategies thought to increase practice include personalized training booklets, group training and technology such as robotic arms or treadmill walking

Motor task training is most effective when the tasks are practiced in the context they will be performed[edit | edit source]

Task and context specific training involves practice of the task that needs to be improved in a variety of environments.For example, to improve transferring people with tetraplegia need to practice transferring. It is essential that transferring is mastered in a simple environment prior to being mastered in more complex contexts.

Motor task training is most effective when sub-tasks are practiced if the whole task is too difficult[edit | edit source]

Practice of sub-tasks often involves adopting a ‘similar but simpler’ approach.That is, if the sub-task is too difficult an easier task may need to be practiced.For example, if a person with tetraplegia is having difficulty with rolling they may initially need to practice a simpler task.

Motor task training is most effective when manual guidance is used appropriately[edit | edit source]

Practice of tasks and sub-tasks often requires manual guidance or assistance from the therapist.For example, if a person with paraplegia is having difficulty with several components of a transfer they may require assistance with one component (such as moving forward in the chair) to enable practice of other components.

Motor task training is most effective when sub-tasks or tasks are progressively made more difficult[edit | edit source]

As simpler sub-tasks are mastered they need to be made more difficult and eventually correctly sequenced into the whole motor task. Once the whole motor task is mastered it is important to continue to practice in progressively more challenging environments.

Motor task training is most effective when clear instructions and demonstrations are used[edit | edit source]

Instructions need to be tailored to the individual however, as a general rule broad instructions are most useful during the initial phases of skill acquisition and specific instructions are most useful in the latter phases.A demonstration (live or via video) of the task or sub-task may also be a valuable adjunct to training.

Motor task training is most effective when feedback is appropriate[edit | edit source]

Appropriate verbal feedback can include information about correct completion of the task (knowledge of results) or information about the key aspects of the task that need to change (knowledge of performance).

Feedback can also be provided visually. For example, scales provide visual feedback about success of lifting.

Function of motor skills training[edit | edit source]

  • Motor training is commonly used to improve balance during functional tasks.
  • Motor training is commonly used to improve rolling and bed mobility.
  • Motor training is commonly used to improve transfers.
  • Motor training is commonly used to improve wheelchair mobility
  • Motor training is commonly used to improve upper limb and hand function.
  • Motor training is commonly used to improve standing and walking

References[edit | edit source]

  1. Bramley A, Rodriguez AA, Chen J, Desta W, Weir V, DePaul VG, Patterson KK. Lessons about Motor Learning: How Is Motor Learning Taught in Physical Therapy Programmes Across Canada?. Physiotherapy Canada. 2018 Nov 30;70(4):365-72
  2. Dobkin BH. Motor rehabilitation after stroke, traumatic brain, and spinal cord injury: common denominators within recent clinical trials. Current opinion in neurology. 2009 Dec;22(6):563.
  3. 3.0 3.1 De Miguel-Rubio A, Rubio MD, Alba-Rueda A, Salazar A, Moral-Munoz JA, Lucena-Anton D. Virtual Reality Systems for Upper Limb Motor Function Recovery in Patients With Spinal Cord Injury: Systematic Review and Meta-Analysis. JMIR mHealth and uHealth. 2020;8(12):e22537.
  4. 4.0 4.1 4.2 Allison GT. The ability to transfer in individuals with spinal cord injury. Critical Reviews™ in Physical and Rehabilitation Medicine. 1997;9(2).
  5. Spooren AI, Janssen-Potten YJ, Kerckhofs E, Bongers HM, Seelen HA. ToCUEST: a task-oriented client-centered training module to improve upper extremity skilled performance in cervical spinal cord-injured persons. Spinal Cord. 2011 Oct;49(10):1042-8.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 Chhabra HS. ISCoS textbook on comprehensive management of spinal cord injuries. Wolters kluwer india Pvt Ltd; 2015.
  7. 7.0 7.1 Kilkens OJ, Dallmeijer AJ, Nene AV, Post MW, van der Woude LH. The longitudinal relation between physical capacity and wheelchair skill performance during inpatient rehabilitation of people with spinal cord injury. Archives of physical medicine and rehabilitation. 2005 Aug 1;86(8):1575-81.
  8. Jones ML, Evans N, Tefertiller C, Backus D, Sweatman M, Tansey K, Morrison S. Activity-based therapy for recovery of walking in individuals with chronic spinal cord injury: results from a randomized clinical trial. Archives of physical medicine and rehabilitation. 2014 Dec 1;95(12):2239-46.
  9. https://www.youtube.com/watch?v=ZPsjb43wO2c
  10. Spooren AI, Janssen-Potten YJ, Kerckhofs E, Seelen HA. Outcome of motor training programmes on arm and hand functioning in patients with cervical spinal cord injury according to different levels of the ICF: a systematic review. Journal of rehabilitation medicine. 2009 Jun 5;41(7):497-505.
  11. https://www.youtube.com/watch?v=PDHRPjnLBIM&feature=emb_logo