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Basic Knowledge - A Movement Therapy

Perspective

Audience

2

Clinicians Scientists Engineers Others

Basic Knowledge - A Movement Therapy Perspective

Audience

3

Clinicians Scientists Engineers Others

Basic Knowledge - A Movement Therapy Perspective

Contents

1. Neurological Principles

2. Key Factors for Recovery

3. Linkage to New Technologies

Basic Knowledge - A Movement Therapy Perspective 4

NEUROLOGICAL PRINCIPLES


1

!

Basic Neuroanatomy


Cells in the brain called neurons control our movement by sending signals to cells in the spinal cord which in turn

connect with the muscles.

!

What determines whether a cell fires?Neural Transmission


The movement signals are relayed from one neuron to another via synapses. The connection strength of synapses is variable

and forms the basis for learning and memory.

!

Central Nervous System Injuries


Our ability to move around can be impaired by damaging neurons in the brain (stroke, TBI) or interrupting the signal pathway

via the spinal cord to the muscles (SCI).

Traumatic Brain Injury Stroke Spinal Cord Injury

!

Motor Impairments after Stroke

Impairments have impacts on activity and participation, independence and quality of life.


49% balance

54% walking

52% hand movement

44% arm movement

44% leg movement

31% require assistance

20% need help walking

16% institutionalized

71% vocationally impaired after 7 years

34% unemployed at <65 years[113]

[114]

!

Mechanisms of Recovery


Recovery is a combination of reversal of injury related factors (edema, diaschisis) and neuroplasticity.

Neuroplasticity

Incident days weeks months yearshours

unmasking

resolution of

edema

resolution of penumbra

resolution of diaschisis

neurotransmitter alterations

synaptogenesis

Injury Reversal

!

Neuroplasticity


The ability of the nervous system to respond to intrinsic or extrinsic stimuli by reorganizing its structure, function and connections.

Harnessing neuroplasticity for clinical applications, Cramer et al. 2011

Neuroplasticity is the modification of the nervous system on a cellular and behavioral level. It is triggered by injury

or activity/training.

!

Activity-Induced Neuroplasticity


Active training enhances neuroplasticity and results in reorganization of cortical maps.

HAND

ELBOWSHOULDER

Rehabilitation

No Rehabilitation

LesionHAND

ELBOWSHOULDER

LESION

HAND

ELBOWSHOULDER

LESION

Pre-infarct Post infarct

Summary: Neural Principles


We move by sending movement commands from neurons in our brain to our muscles.

The signals are transmitted from neuron to neuron via synapses which can adjust their relay strength allowing us to

learn and improve movements.

Damage to the neurons in the brain or interruption of the signal pathway result in motor impairments which negatively

impact our daily life.

Recovery happens to some part spontaneously by resolving injury-related factors but also due to neuroplastic

processes.

Repeated activity and training triggers neuroplasticity which modifies the central nervous system to recover

functionality.

KEY FACTORS FOR RECOVERY


2

!

Key Factors for Recovery


Neuroplasticity and learning can be driven by several key factors taken from motor learning theory.

Manner

• Task segmentation

• Specificity /

Functionality

• Variability

• Initiation

• Shaping

Intensity

• Repetitions

• Duration

• Distribution /

Frequency

• Effort

• Difficulty Psychological

Factors

• Motivation

Information

• Instructions

• Feedback

!

Intensity: Overview


Therapy needs to be intensive, active and challenging for optimal recovery to take place.

Intensity

• Repetitions

• Duration

• Distribution /

Frequency

• Effort

• Difficulty

Repeated performance of a movement/task

Time of a single therapy session or entire therapy

Amount of rests between repetitions or therapy sessions

Active participation of the patient (physical and mental)

Level of challenge during therapy sessions

Duration

Repetitions

Frequency

Difficulty of task

Effort

Intensity: Overview


Intensity = x

!

Intensity: Repetitions

Power law of practice

“All other things being equal, the degree of performance improvement depends on the amount of practice [1,2].”

More is better

Increasing the amount of task repetitions results in cortical changes and better functional improvement [11–13, 17].”

How much is enough?

Evidence from animal and human studies suggests a much higher amount of repetitions for upper [3-7] and lower limbs [8-10] compared to the current therapy standard [31-32].


More repetitions lead to improved outcomes. A minimal amount of repetitions might be required for recovery to take

place.

0

1500

3000

4500

6000

7500

9000

10500

4 6 8 10 12 14 16 18 20

Estim

ated

Acc

umul

ated

Prac

tice

(Hou

rs)

Age of Violinists (Years)

Best

Good

Teachers

Professionals

!

Intensity: Duration

Practice Duration

Duration of practice is a key factor in meaningful training after stroke, and

additional practice is better [33-36].

Average therapy session

Inpatients in the UK receive on average 30.6 minutes physical therapy per day of

therapy [16].

Optimal practice duration

According to Wang et al. the threshold duration for optimal outcome in stroke

inpatients is 3 hours of therapy per day [36].


In general, more therapy hours results in better outcomes. Due to cost and limited manpower current therapies

provide only low therapy times.

Time

Mo

tor

fun

ctio

n

standard therapy

intense therapy

!

Intensity: Distribution and Frequency

Benefits of rest periods

Frequent and longer rest periods between repetitions (distributed practice)

improve learning compared to no rests (massed practice) in healthy

subjects[14].

Trade-off

Massed practice enables increased amounts of training per time. On the other

hand resultant fatigue and tiredness of massing practice increase the chance of

injury.


There is weak evidence that distributed practice might be better for a safe and effective therapy than massed

practice.

!

Intensity: Effort

Importance of physical effort

Active generation of controlled movements are necessary for effective learning [18-19, 38, 21].

Disadvantage of too much assistance

Movement assistance can reduce physical effort and therefore diminish skill learning [39].

Increasing task difficulty can lead to increased effort [22]

Optimal cognitive demands

Increasing levels of mental effort up to a point are generally beneficial for learning [40-42].

Overwhelming patients on the other hand interferes with learning [43].


Patients should participate as actively as possible and be cognitively challenged without being overwhelmed.

!

Intensity: Difficulty

Challenge beyond present capabilities

Learning is optimal when difficulty is out of “comfort zone”.

More complex tasks enhance short and long term neuronal changes

[20].

Enable training in optimal conditions

Support and guidance can help to avoid “over-challenge”.


Training should be adjusted for each patient for an optimal challenge. The optimal learning difficulty is not identical with thedifficulty under which performance is greatest.

“comfort zone” optimal learning

over-

challenge

!

Manner: Overview


Therapy should start early, focus on practice of tasks used in daily life and include a high amount of variability.

Training a simplified version or only a part of a movement

Training of specific, essential tasks used in daily life

Amount of diversity or randomness contained in a task performance

Continuously adjustment of task difficulty combined with reinforcement

Manner

• Task segmentation

• Specificity /

Functionality

• Variability

• Initiation

• ShapingTiming of the therapy start

!

Manner: Task segmentation

Types of task segmentation

Fractionalization: Breaking bilateral tasks into two unilateral parts.

Progressive part practice: Separate task into several subparts.

Simplification: Reducing complexity of the task or parts of it.

Benefits of part training

Serial tasks containing distinct segments can be learned more effective in parts [23-24].

Segmentation of complex tasks can enhance performance in stroke patients [44].

Benefits of whole training

Continuous tasks such as walking and fast, discrete tasks should be learned as whole [1].


Tasks should only be broken down into parts if composed of distinct subparts or if the whole task proves to be too

difficult to learn.

!

Manner: Specificity / Functionality

Benefit of task specific training

Task oriented training improves function and changes cortical activation [27,

62].

Make it more real!

Practice with real objects significantly improves reaching kinematics [63,

64].


Patients should focus practice on activities essential in daily-life in a setting which is as realistic as possible.

Shorter movements when grasping a cup if the intention is to drink compared to just taking it [26].

Transfer of practice

Practice conditions need to match the real life situation as close as possible to facilitate daily tasks [25].

!

Manner: Variability

Benefits of variable practice

Task variability improves learning and increases the ability to perform new tasks [28-29].

Forgetting helps remembering

Alternating randomly between training of multiple tasks (random practice) seems to be more effective than constant practice (blocked practice) in improving motor function in stroke patients [15].

Dependency on nature of task

Relative timing of closed tasks might be more effectively learned by constant practice [30].


In general, practicing a task with variable setting or in a random order improves learning and the ability to

generalize.

!

Manner: Initiation

Very early, intense therapy might be harmful

Some animal studies have shown worse outcomes if therapy started with high intensity right after a stroke [47].

Window of opportunity

There is evidence that early rehabilitation leads to better outcomes but no optimal time ranges have been established. Recovery

decreases the longer therapy is delayed [52, 65, 93].

Benefits of early mobilization

Early mobilization reduces medical complications and decreases time to achieve functional walking [88].


Current evidence suggests to start rehabilitation early after the incident.

!

Manner: Shaping

Benefits of shaping

Shaping is an important way for enhancing recovery success, especially in the upper limbs [45-46].

Shaping can be combined with constraining of the unaffected limb to further increase effectivity [46].

Optimal motivation level

Shaping is important to avoid frustration but also to avoid boredom [67].


“Shaping or adapted task practice is defined as a method in which a motor or behavioral objective is approached in small steps by successive approximations or by making the task more difficult in accordance with the patient’s motoric capabilities.”

Wolf et al. 2002

Adjusting task challenge in small steps while encouraging (reinforcing) improvement is an effective practice

method.

motor

function intensity

time

!

Psychological Factors: Overview


Motivation is very important for adhering to intensive therapy and leads to improved training outcomes.

Psychological

Factors

• Motivation Motivation to practice and perform tasks

!

Psychological Factors: Motivation

Effect of Motivation

Patient motivation is key factor for a positive rehabilitation outcome [48-49].

Low Motivation

Lack of motivation is a major cause of failure to benefit from rehabilitation [50].

In addition, rehabilitation staff and family members report low motivation as one

of the most debilitating symptoms they deal with in rehabilitation [51].


Motivation has a strong influence on successful rehabilitation. Low motivation negatively affects patients,

rehabilitation staff and family members.

0

5

10

15

20

25

30

35

15 30 45 60 75 90

Perf

orm

ance

sco

re

Average Weekly Practice (minutes)

high motivation

medium motivation

low motivation

!

Psychological Factors: Motivation

Making the task seem important

Adding meaning to exercises can serve as an intrinsic motivator and enhance performance [53].

Effect of Goal-setting

Specific goals that are adjusted during practice lead to improved learning compared to telling people to do their best [54].

Benefits of positive feedback

Positive (normative) feedback has a motivational effect that can enhance learning [55].


There exist a variety of ways to increase motivation can be increased which benefit learning.

!

Information: Overview


Information can critically influence learning in a positive or negative way. Giving too much and redundant

information should be generally avoided.

Information given before practice to facilitate correct performance

Information

• Instructions

• Feedback Information signaling outcome and correctness of performance

!

Information: Instructions

Effect of instructions

The way instructions change a subjects focus can have detrimental effects on performance and learning [56].

Usage of instructions

Only convey general ideas which are essential for first trials. Add more instructions progressively due to limited amount of instructions

that can be remembered [1].

Optimal schedule

Interspersing active practice with visual demonstration of the task improves learning compared to just giving a block of demonstrations

before practice [58-61].


Instructions can assist with learning if used in the right way (sparsely intermixed with practice).

!

Information: Feedback Overview


Sensory feedback is essential for learning references of correctness which allow us to detect errors from sensory

information.

• Feedback plays an essential role for movement control and learning

• Can be visual, auditory, olfactory, gustatory, somatosensory

• Used to compare an actual movement with the desired movement to detect errors and guide optimal movement form

• Feedback is required to learn unfamiliar tasks

Information: Feedback Types


Knowledge of

Results

(KR)

Knowledge of

Performance

(KP)

Augmented

(extrinsic)

Inherent

(intrinsic)

Proprioceptive Exteroceptive

Visual Auditory Tactile

Feedback

Vision Haptic

!

Information: Inherent Feedback


Sensory feedback with meaningful movements determines effectiveness of training.

Upper limbs

Synchronization of afferent feedback with voluntary movement is

useful for motor recovery facilitating neural plasticity [77-78].

Lower limbs

Afferent input is important for locomotor pattern and effectiveness

of training [79].

!

Information: Augmented Feedback

Usefulness of Augmented Feedback

Augmented feedback is a major element for motor optimization [66-67, 69].

Because inherent feedback mechanisms are often impaired augmented feedback can be of even greater importance for rehabilitation

[68].

Effect of Augmented feedback

Increases the rate of skill acquisition, promotes more efficient movements and encourages learning [70].

Has no beneficial effect if inherent feedback provides already the same information [71].


Augmented Feedback is a major factor to influence motor learning unless the same information is contained in the

inherent feedback.


Detrimental effect of Feedback - «Guidance hypothesis»

Learner can become dependent on augmented feedback, possibly at the expense of relying on his own inherent sources of sensory

information to support performance under nonaugmented test conditions [69, 94, 95].

Optimal use of Feedback

Performance is optimal when acquisition and subsequent test conditions are similar in terms of available feedback sources [96].

Simple motor skills

Providing feedback about the outcome benefits learning of simple motor skills [97].

Learning in simple tasks can be increased by reducing or delaying the presentation of augmented feedback [98].


!


Complex tasks

More complex tasks benefit from feedback about the movement

performance [1].

Frequent feedback presentation can enhance learning of complex

skills [99].

Usage in Rehabilitation

Feedback about the movement performance might be useful for

patients due to unguided practice leading to compensatory

movements [100,101].


Augmented feedback should generally be given in the beginning of therapy but reduced over time to prevent

dependency.

mot

or fu

nctio

n

t

!


Positive and negative feedback

Feedback after good trials compared to poor trials enhances learning [102,103].

Feedback indicating errors might heighten self-related concerns or worries that may negatively affect learning.

The mere conviction of being ‘good’ or ‘better than average’ enhances learning [104].

Self-controlled feedback

Leads to more effective learning than predetermined feedback schedules [105].

Feedback cannot merely be viewed as information without any affective connotation.


!

Information: Guidance

Effect of Guidance

Guidance is in general detrimental for learning [106-108]. But interspersed with active practice guidance can be beneficial [109-110].

Benefit of Guidance

Useful for preventing injury and reduce fear [1].

Probably most useful for early practice and slow tasks [1].

Learning of complex tasks can benefit from guidance [111, 112].


A procedure used to direct (either physically, verbally and/or visually) learners through task performance in an effort to reduce errors or reduce fears.

Schmidt and Wrisberg, 2008

Guidance should probably be kept to a minimum unless there is danger of injuring oneself or the task is to complex

or not possible without it.

Summary: Key Factors of Recovery


Key factors underlying motor learning can drive neuroplasticity and recovery.

Therapy needs to be intensive, active and challenging for recovery to take place.

Therapy should start early and focus on specific tasks related to activities of daily living.

Practice should be variable and intermix different tasks while therapy goals should be approached in small steps

reinforcing patient’s progress.

Motivation is very important for an effective therapy and can be increased by making the training enjoyable and goal-

oriented.

Instructions play an important role but need to be carefully chosen.

Feedback and guidance should be provided early during therapy but be reduced with time to avoid a dependency on it.

LINKAGE TO NEW TECHNOLOGIES


3

New Technologies: Overview


«Application of robotic devices to assist, enhance and intensify

therapy.»

«Use of non-actuated devices (no motors) such as body weight support systems to facilitate

rehabilitation.»

«Application of electrical stimulation to create functional

movements and improve recovery.»

Non-Actuator

DevicesRobotics

Functional Electrical

Stimulation

New Technologies: Overview


«Use of virtual reality and environments for enhancing

movement therapy.»

«Use of sensors (motion, force etc.) for assessing and enhancing

therapy.»

«Application of electrical stimulation to the brain for

enhancing recovery.»

Virtual Reality Sensor Technology Brain Stimulation

Advantages of New Technologies

Labor and therapy costs

saving


Home useGreater consistency of

therapyNever tiring out Highly motivating

Precise measurements

& assessments

Optimized patient

support

Issues of New Technologies


Costly

$

Less flexible than

therapistRisk of obsolescence Space consuming

XL

Linkage to New Technologies


Larger number of repetitions

• automated administration [72]

• assistance for impaired patients [73-74]

Increased practice time

• high motivation [75]

• lesser need for supervision

• home-based practice [76]

Repetitions Duration



Increased effort

• adding resistance [80, 81]

• increased motivation

Adjustable difficulty [72]

• added resistance

• reduced support

• adjusting feedback

Effort Difficulty



Task simplification

• bilateral/unilateral practice [82]

• partial movements [83]

• reduction of degrees of freedom

Functional training [84, 85]

• simulate virtually with haptic feedback

• in reality combined with accurate sensing

Segmentation Task specificity



Shaping [86]

• step by step adaption of task complexity

(assistance, resistance)

Increased motivation

• immersion through gamification [80, 87, 89]

• encouraging feedback

• goal-setting [90]

• success through assistance [90]

Shaping Motivation



Augmented Feedback

Providing instructions

• verbal, visual [91-92]

Providing feedback

• inherent feedback

• augmented feedback

• precise timing

• assistance as-needed

Instructions Feedback

A great number of ways for timed and precise instructions as well as presentation of feedback are available.

Many options exist to provide a much higher motivation than compared to conventional therapy.

Practice can be scheduled efficiently in a task specific and variable manner.

New technologies can provide more intensive and longer trainings adjusted to the individual patient level enhancing

capacity for recovery.

Some new technologies still have a few issues which are normally outweighed by the advantages.

New technologies have many advantages for application in therapy.

Summary: Linkage to New Technologies


Contact

International Industry Society in Advanced Rehabilitation Technology

(IISART)

General Information

[email protected]

www.iisartonline.org


http://www.iisartonline.org/

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Literature

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[112] Wulf and Toole 1999, Physical assistance devices in complex motor skill learning: Benefits of a self-controlled practice schedule.

[113] NSA survey:

http://www.stroke.org/site/DocServer/StrokePerceptions_FinalS

urveyResults_2006.pdf

[114] NSA stroke guide: http://surgeonwriter.com/wp-

content/uploads/2014/05/NSA-Stroke-Guide.pdf


Image sources

Slide 2 – Audience

Background: http://www.iisd.ca/ymb/climate/wcc3/pix/1sept/DSC_6266%20full%20room.jpg

Slide 5 – Basic Neuroanatomy

Left, middle, right images: Created for slide pool by Gokcen Akcali

Slide 6 – Neuronal Transmission

Left, middle, right images: Created for slide pool by Gokcen Akcali

Slide 7 – CNS Injuries

Left image: http://www.pialaw.ca/

Middle image: http://www.merckmanuals.com/

Right image: http://www.nlm.nih.gov/medlineplus/ency/imagepages/

Slide 8 – Motor Impairments after Stroke

Left Image: http://www.rgbstock.com/bigphoto/n3hzesC/Old+man

Right Image (rollator): https://plus.google.com/+VomrheinDe/posts/HdJcmQh3ZNE

Slide 9 – Mechanisms of Recovery

Image created from: Evidence-Based Review of Stroke Rehabilitation: Background Concepts in Stroke Rehabilitation

Teasell and Hussein (2013)


http://www.iisd.ca/ymb/climate/wcc3/pix/1sept/DSC_6266 full room.jpg

http://www.pialaw.ca/wp-content/uploads/2014/04/traumatic_brain_injuries_hv.png

http://www.merckmanuals.com/home/brain_spinal_cord_and_nerve_disorders/stroke_cva/ischemic_stroke.html

http://www.nlm.nih.gov/medlineplus/ency/imagepages/

http://www.rgbstock.com/bigphoto/n3hzesC/Old+man

https://plus.google.com/+VomrheinDe/posts/HdJcmQh3ZNE

Image sources

Slide 10 – Neuroplasticity

Series from: Taub et al. 2002, New treatments in neurorehabilitation founded on basic research

Slide 11 – Activity-Induced Neuroplasticity

Monkey brain: http://upload.wikimedia.org/wikipedia/en/d/d9/Motor_Cortex_monkey.jpg

Cortex areas: Nudo et al. 2001, Role of adaptive plasticity in recovery of function after damage to motor cortex

Slide 14 – Key Factors for Recovery

Central image: Slide from Clemens

Slide 17 – Intensity: Repetitions

Graph: Adapted from: Ericsson et al. 1993, The role of deliberate practice

Slide 18 – Intensity: Duration

Graph: Created for slide pool

Slide 19 – Intensity: Distribution and Frequency

Graph: Schmidt and Lee 2005, Motor control and learning

Slide 21 – Intensity: Difficulty

Graph: Adapted from Guadagnoli and Lee 2004, Challenge point: A framework for conceptualizing the effects of various practice conditions in motor

learning


http://upload.wikimedia.org/wikipedia/en/d/d9/Motor_Cortex_monkey.jpg

Image sources

Slide 24 – Manner: Specificity / Functionality

Image: https://www.helenhayeshospital.org/wp-content/uploads/2010/07/armeo_machine.jpg

Slide 27 – Manner: Shaping


Slide 29 – Psychological Factors: Motivation

Graph: Adapted from Daniel Coyle 2009, The talent code: Greatness Isn't Born. It's Grown. Here's How.

Slide 34 – Information: Feedback Types

Left image: Tennis stroke: http://www.optimumtennis.net/images/federer-forehand-grip.jpg

Right image: Hawk eye: http://www.thesixthaxis.com/wp-content/uploads/2011/03/tennistech-e1299666034139.jpg

Slide 35 – Information: Inherent Feedback

Image: Slide/image from Clemens

Slide 38 – Information: Augmented Feedback


Slide 43 – New Technologies: Overview

Robotics: http://products.iisartonline.org/products/22/photos/22.jpg

Non-actuator devices: http://products.iisartonline.org/products/50/photos/50.jpg

FES: http://products.iisartonline.org/products/80/photos/80.jpg


https://www.helenhayeshospital.org/wp-content/uploads/2010/07/armeo_machine.jpg

http://www.optimumtennis.net/images/federer-forehand-grip.jpg

http://www.thesixthaxis.com/wp-content/uploads/2011/03/tennistech-e1299666034139.jpg

http://products.iisartonline.org/products/22/photos/22.jpg



Image sources

Slide 44 – New Technologies: Overview

Virtual Reality: http://products.iisartonline.org/products/60/photos/60.jpg

Sensor technology:http://products.iisartonline.org/products/49/photos/49.jpg

Brain stimulation: http://psychiatry.duke.edu/files/pictures/072911_lisanby011_fpo.jpg

Slide 45 – Advantages of New Technologies

Icons: Adapted for this slide pool

Slide 46 – Issues of New Technologies

Icons: Adapted for this slide pool

Slide 47 – Linkage to New Technologies

Repetitions: Hocoma image

Practice time: http://www.minutehound.com/time-clock-blog/time-clock-in-the-corporate-environment/time-clock-sand/


Increased effort http://c1.staticflickr.com/1/82/244870160_416de4dbaa_z.jpg, Tug of War by toffehoff via Flickr. Creative

Commons: https://creativecommons.org/licenses/by-sa/2.0/legalcode

Difficulty http://www.androidtapp.com/wp-content/uploads/2012/07/Birds-Difficulty.jpeg




http://psychiatry.duke.edu/files/pictures/072911_lisanby011_fpo.jpg

http://www.minutehound.com/time-clock-blog/time-clock-in-the-corporate-environment/time-clock-sand/

http://c1.staticflickr.com/1/82/244870160_416de4dbaa_z.jpg

https://creativecommons.org/licenses/by-sa/2.0/legalcode

http://www.androidtapp.com/wp-content/uploads/2012/07/Birds-Difficulty.jpeg

Image sources


Segmentation: Created for this slide pool

Specific training: Hocoma


Shaping: Created for this slide pool

Motivation: Created for this slide pool


Instructions: http://informatics.northwestern.edu/blog/wp-content/uploads/2012/01/ikea_assembly_instructions.jpg

Feedback: Adapted for this slide pool (Slide from Clemens)


http://informatics.northwestern.edu/blog/wp-content/uploads/2012/01/ikea_assembly_instructions.jpg

basic knowledge - a movement therapy perspective · basic knowledge - a movement therapy...

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