Table 1 Theoretical background of the standardized PT program
Muscle stretching /relaxation and mobilisations (de Morree[43], Fung[44]) | ||
Principle | Explanation | Application in standardized PT program |
1. Passive mobilisation of the neck | Passive mobilization techniques of the neck create stress relaxation in the collagen fibers of the cervical facet joints. This helps to increase ROM | Passive mobilisation techniques are applied by PT’s |
2. Muscle stretching for relaxation | Stretching elongates the dystonic muscle and helps to relax it due to the Golgi tendon reflex. | Passive stretching of dystonic muscles |
Motor learning principles (Kleim & Jones[20]) | ||
Principle | Explanation | Application in standardized PT program |
1. Use it or lose it | Failure to drive specific brain functions can lead to functional degradation. | Activation of antagonists |
2. Use it and improve it | Training that drives a specific brain function can lead to an enhancement of that function. | Training of antagonists in order to improve voluntary movement of the head |
3. Specificity | The nature of the training experience dictates the nature of the plasticity. | Functional training of activities of daily living tailored to the patients needs |
4. Repetition matters | Induction of plasticity requires sufficient repetition. | Exercise of newly gained tasks 5–10 times a day for 10–15 minutes |
5. Intensity matters | Induction of plasticity requires sufficient training intensity. | Training intensity is tailored for the individual and monitored over time |
6. Time matters | Different forms of plasticity occur at different times during training. | 1 year of therapy is divided in 3 stages according the 3 stages model of Fitts & Postner [45] |
7. Salience matters | The training experience must be sufficiently salient to induce plasticity. | Functional training of activities of daily living tailored to the individual needs of the patient |
8. Age matters | Training-induced plasticity occurs more readily in younger brains. | Â |
9. Transference | Plasticity in response to one training experience can enhance the acquisition of similar behaviors. | Functional training of activities of daily living tailored to the patients needs and variation and random practice |
10. Interference | Plasticity in response to one experience can interfere with the acquisition of other behaviors. | Â |
Transference and generalization (Shea & Morgan[45], Schmidt & Lee[46]) | ||
Principle | Explanation | Application in standardized PT program |
1. Random practice | Enhances the transference and generalization of a task | Tasks or exercises are given in a random order |
2. Variation of practice | Enhances the transference and generalization of a task | Specific tasks or exercises are performed in different contexts |
Principle | Explanation | Application in standardized PT program |
1. Summary Knowledge of Results | Feedback is essential for learning to take place. Summary KR is that KR is given after an entire set of trials during an exercise instead of after each individual trial. It is the most effective form for the retention and transference of a task. | Feedback is given after each set of trials of a task. Each task is performed at least 5 times after feedback is provided |
Self management (Fitts & Posner three-stage model[48]) | ||
Principle | Explanation | Application in standardized PT program |
1. Cognitive phase | The learner is concerned with understanding a task and developing strategies to perform a task and how the task can be evaluated. These efforts require a high degree of cognitive activity | During the first month patients receive 2 PT sessions a week to (re)learn and understand movement strategies. Movement strategies will be practiced at home 5–10 times a day for 10–15 minutes |
2. Associative phase | The learner has selected the best strategy for a task and starts to refine it. This stage requires less cognitive activity | During this stage patients receive 1 PT session. Movement strategies from the first stage will be increased in difficulty. Movement strategies will be practiced at home 5–10 times day for 10–15 minutes |
3. Autonomous phase | The learner is able to perform a skill automatically. A low degree of attention is required. | During the last (autonomous) stage, patients are encouraged to perform the learned tasks independently and to improve and maintain their (re)gained abilities themselves. Therapists will have a coaching role. Patients receive one PT session a month for additional advice and motivation. |