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Neuroplasticity in the Clinic: U$lizing Evidence To Maximize Par$cipa$on in Occupa$on for Individuals With Stroke
Christine Griffin, OTR/L MS,BCPR Ohio State University Medical Center
Evolu$on of Rehab Interven$on
• Evidence Based Prac$ce – Are we able to prove that what we are doing is effec$ve?
• AOTA Centennial Vision • Closely examine what our interven$on for survivors of stroke require and what is effec$ve
• Stroke is one of the top health condi$ons treated by Occupa$onal Therapists – (Go et al, 2013)
Neurofacilitation Techniques
• Brunnstrom’s Movement Theory – Limited Evidence
• Wagennar et al. (1990) – Brunnstrom phases vs NDT phases, n = 7 – Time series walking speed analysis – One par$cipant performed be\er with Brunnstrom than NDT
• Sawner & LaVigne, 1992 – Studies (25) cited to support the approach were published between 1898-‐1960
Neurofacilitation Techniques
• Propriocep$ve Neuromuscular Facilita$on – Smedes, 2006 Systema$c review of 4 RCT
• In a home and structured program Inclusive PNF is effec$ve, treadmill training is more effec$ve than PNF on gait, and NMES is more effec$ve than PNF on hand func$on
• Rood – No Evidence
Neurofacilitation Techniques • NDT/Bobath
– Langhammer et al, 2000 • Motor learning be\er than Bobath
– Tang et al, 2005 • Task oriented approach be\er than NDT
– Hafsteonsdofr et al, 2005 n=324 • Bobath vs standard therapy • No difference, Bobath group had more treatment sessions
– Systema$c Reviews • Kollen et al. (2009) Bobath Concept is not superior to other approaches
• Rao (2011) Lack of effec$veness of the Bobath approach when compared with a task-‐oriented approach
• Arya (2012) Task oriented approach be\er than NDT
Neurofacilitation Techniques
• Proprioceptive Neuromuscular Facilitation, Rood, and Brunnstrom Approach – Evidence “sparse and inconclusive”
(Sabari, 2010) – Based on outdated views of motor recovery and motor control
(Ma & Trombly, 2002; Pollock, Baer, Pomeroy, & Langhorne, 2007; Steultjens et al., 2003)
• Neurodevelopment Treatment – No evidence of significantly better outcomes for NDT when
compared with other treatments to improve upper limb motor function (Luke, Dodd, & Brock, 2004; Packi, 2003)
– Task Oriented Training is superior to NDT (Wolf & Nilsen, 2015)
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Shih in Rehabilita$on Approach
• Self Examina$on • Interven$on supported by Evidence and Research
• Paradigm shih from tradi$onal theories to Neuroplas$city – Task Oriented Training
Neuroplasticity – What is it?
• Neuroplas$city à Changing the brain • Capability of CNS to alter func$on and structure in response to use and motor learning
• Reorganiza$on of undamaged systems in the brain
• The brain responds to func$onal/ environmental demands
• Occurs aher Repe$$ve Prac$ce (Lundy-‐ Ekman, 2007, Kass, 1991, Donoghue et al, 1991)
Neuroplasticity
• Borders of neuro mapping are not defined – Brain is moldable according to the will and
actions of the individual • Nudo (2001)
– Adaptive plasticity in motor cortex – Functional and structural dynamic nature of
the cerebral cortex
Neuroplasticity • Possible Explanations
– Areas of the brain assume functions that were once the responsibility of a damaged area of the brain
– Areas of the brain lay dormant until needed to assume functioning for damaged regions
– Creating new pathways for the connections between neurons
(Gutman, 2008)
Repetitive Practice
• High Intensity/ High Repetition → Cortical Changes
• Motivational Strategies for Patient – Self control vs. External Control
• Patient education – Importance of intensity of repetition – Intensive HEP
Learned Non- Use
• Decrease is muscle/ motor activity → decrease in function → frustration → avoidance of activity
• What happens cortically? • Kleim (1998)
– Motor cortex representation diminishes with immobilization beyond nine days
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Neuroplasticity is Skill/ Activity Dependent
• Nudo, 2001 – Plasticity is limited to behavioral experiences
• Nudo, 2003 – Plasticity of the motor cortex are skill-
dependent rather than simply use dependent. • Cauragh, 2005
– Upper extremity gains evolve from motor experiences and activity-dependent interventions
Chronic Recovery
• Thickbroom, 2004 – Purpose: Investigate the relationship between
changes in motor cortex organization and degree of motor function after stroke
– Subjects: 27 pt’s with upper limb motor deficits up to 23 yrs after onset
– Intervention: The hand’s corticomotor area was mapped with transcranial magnetic stimulation. Motor Assessment Scale and grip strength measurement were used as functional assessments. Task oriented treatment was provided
Thickbroom (Clin Neurophysiol 2004)
– Results: After treatment, motor maps of the hand showed displacement in 17 pt’s. Ten pt’s showed normalization of corticospinal conduction and a positive correlation between the magnitude of the map shift and grip strength in the affected hand.
– Conclusion: The present findings provide evidence that cortical plasticity and reorganization occurring after a stroke is functionally significant.
Neuroplasticity
• Active repetitive task oriented motion
• Task Oriented Training – Functional tasks that use dynamic interaction
between person, task, and environment – Improves occupational performance
(Wolf & Nilsen, 2015)
Methods of Neuroplasticity
• Constraint Induced Movement Therapy • Repetitive Task Practice • Mental Practice • Mirror Therapy • NMES
Constraint Induced Movement Therapy (CIMT)
• Forced use to counteract learned nonuse – Pa$ent unsuccessful with use of affected limb, so would stop ini$a$ng use of limb during tasks
• Restraint of unaffected hand/ arm
• Motor inclusion criteria – 10 MCP extension and 20° wrist extension – Distal func$on is a cri$cal factor (Wolf, 2006)
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Constraint Induced Movement Therapy (CIMT)
• Main factor – Massed prac$ce during repe$$ve func$onal ac$vi$es • Restric$on of less effected arm 90% of day during a 2 week period
• Par$cipa$on in upper limb therapy program 6hrs/day during the 2 week period
• Shaping is very important (picking appropriate ac$vi$es) – Select tasks that address the motor impairment and pa$ent is able to carry out parts of the motor sequence
– Has direct rela$onship to success of treatment (Taub et al, 1999)
What is shaping
• Pacing and modifying an the environment for the ac$vity to obtain the pa$ent maximal performance
• Just right challenge for the client • Breaking down an ac$vity you want to complete into stages that become increasingly more difficult.
• Increase or decrease the environment ac$vity demands on a person while he or she is performing an ac$vity
Things you can grade • Distance to reach or step • Timed/ un$med • Speed • Dura$on • Quali$es of object • Environment • Contextual interference • Several tasks learned and
prac$ced together • Demands (standing/ sifng) • Number of repe$$ons
• Object placement • Complexity: amount of
steps • Amount of cues or
assistance given • Number and kinds of
distrac$ons during tasks • Gravity factor
– With gravity → gravity eliminated → gravity
Pa$ent’s Perceived Difficulty of Performing Task
• Perceived Difficulty: 1-‐10 Scale – 1 = Easy – 10 = Impossible
• Influences pa$ents par$cipa$on and perceived value of the therapy session
• Trends of pa$ent’s reported perceived difficulty of performing tasks – 1-‐3 Easy (“Boring”) – 4-‐5 Medium Difficulty – 6-‐8 Good Challenge (“The Sweet Spot”) – 9 Almost too difficult – 10 Impossible
Graded task with a stroke pa$ent, Seated, Standing, side lying , Case Study # 1
Video from personal collection of Christine Griffin. Used with permission.
EXCITE: Trial, Wolf et al, 2006
• EXCITE: Extremity Constraint – Induced Therapy Evaluation – Multi-Center, 222 subjects, over 3 yrs – 6 hrs/ day, 5 days/ week, 2 weeks – Significant improvement in Wolf Motor
Function Test and Motor Activity Log – Lasted 24 months later
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CIMT
• Neuroplas$cty – Induces cor$cal representa$on of the affected upper limb
• Effects sustained for at least 2 years aher interven$on • Beneficial treatment for pa$ents with some ac$ve wrist
and hand mo$on • Taub et al, 2006 • Boake et al, 2007 • Dahl et al, 2008 • Myint et al, 2008
Modified CIMT
• Dosing – Restric$on of less effected arm 5 hrs/day, 5 days/wk
– Par$cipa$on in upper limb therapy program 1 hr/ day, 3 days/ week, 10 weeks
• mCIMT performed be\er on Fugl-‐Meyer and Ac$on Research Arm test than “usual care” following treatment and at 12 month follow up
(Page et al, 2002, 2004, 2005)
CIMT -‐Timing • Teasel, ebrsr.com 2013 • Acute
– “There is conflic$ng evidence of benefit of CIMT in comparison to tradi$onal therapies in the acute stage of stroke”
– “There is strong (Level 1a) evidence of benefit of mCIMT in the acute/subacute stage of stroke”
• Chronic – “There is strong evidence of benefit of CIMT and mCIMT in comparison to tradi$onal therapies in the chronic stage of stroke. Benefits appear to be confined to stroke pa$ents with some ac$ve wrist and hand movements, par$cularly those with sensory loss and neglect”
Repe$$ve Task Prac$ce
• Based on systems model of motor control and theories of motor learning
• Goal directed, individualized tasks with intensive repe$$ons
• Task related or task specific movement (Wolf & Nilsen, 2015, Carr and Shepherd, 2003, and Gen$le, 2000)
Posi$ve Effects of Repe$$ve Task Prac$ce/ Task Oriented Approach on Impairment level
and Func$on • Barker et al., 2008 • Blennerhasset et al.,
2004 • Caraugh et al., 2006 • Michaelson et al., 2006 • Nelles et al.,2001 • Stinear et al., 2008 • Theilman et al., 2004 • Winstein et al, 2004
• McDonnell et al, 2007 • Boyd et al., 2010 • Arya et al., 2012 • Corti et al., 2012 • Page et al., 2012 • Patten et al., 2013
Repe$$ve Task Prac$ce/ Task Oriented Approach
• Hubbard et al, 2009, Systema$c Review – “We recommend that task-‐specific training be rou$nely applied by occupa$onal therapists as a component of their neuromotor interven$ons, par$cularly in management related to post-‐stroke upper limb recovery”
• ebrsr 2013, systema$c review – There is strong (Level 1a) evidence that repe$$ve task specific training techniques improve measures of upper extremity func$on
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Task Based Practice Opportunities
• Improved function of hemiplegic upper limb when using functional objects and activities
vs. performing similar movement sequences in the
absence of task performance – (Wu, Trombly, Lin, and Tickle-Degnen, 1998; Trombly and
Wu, 1999; Wu, Trombly, Lin, and Tickle-Degnen, 2000; Fasoli, Trombly, Tickle-Degnen, and Verfaellie, 2002; Smedley et al., 1986; Winstein et al., 2004)
• Client’s are not making connection between non-functional activities and functional outcomes
Real Life Challenges
• Busy caseload • Produc$vity standards • Limited $me • Challenging pa$ents and family members • Non-‐produc$ve $me: Documenta$on, mee$ngs, in-‐services, etc.
Occupa$on Kits • Treatment kits made prior to treatment session • Lower Level – Gross Grasp
– Placing ea$ng utensils in organizer – Placing magazines in organizer – Table sefng for 8 – Removing dishes from drying rack – Placing tools in tool box – Placing CD’s in rack – Placing cooking utensils in tall container – Placing folded socks in bin/ drawer – Placing cans/jars on shelving
Occupa$on Kits Higher Level – Bilateral coordina$on and fine motor coordina$on
– Folding clothes in laundry basket
– Hanging clothes on retractable clothes line
– Packing a suitcase with clothes – Pufng ba\eries in remote
control – Pufng toilet paper on holder
and pull off a sheet – Installing toilet paper holder
on base – Sanding plywood – Installing a door knob – Installing a smoke alarm
– Sor$ng and assembling assorted sized nuts and bolts
– Separa$ng and placing play money in wallet
– Coins in coin bank or change purse
– Medica$on into pill organizer – Wrapping a gih/ package – Stuffing envelopes – Sor$ng paper clips – Cufng and stapling paper – Sor$ng coupons – Scrap booking
Mental Practice - Imagery
• Rehearsing task or series of tasks mentally – Cognitive Rehearsal
• No physical activity • Athletes – Sports psychology • Supplement conventional therapy • Used at any stage in recovery
• (Braun et al., 2006, & Jackson et al., 2001)
Mental Practice
• Activates the musculature in the same pattern that correlates with imagined movements – measurable on EMG
• Activates the cortical representation in the same pattern that correlates with imagined movements – measurable on fMRI
• Improves learning & performance • Reorganizes motor cortex - Neuroplasticity
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Mental Practice
• Most plausible mechanism to explain – “Stored motor plans
for executing movements can be accessed and reinforced during mental practice”
(Page, 2001)
Photos from personal collection of Christine Griffin. Used with permission.
Mental Practice – How is it done?
• Audio recording 1. Period of deep relaxation (3-5 min.) 2. Mental Practice Portion
• Involve every aspect of the experience including size of room, and full description of the movement including the feel of the movement.
• “Imaging you are sitting in your favorite chair. The room is quite. There is a table in front of the chair” “imagine there is a cup of that table with fresh apple juice in it. Feel yourself reaching for the cup. Feel the weight of your arm as you reach out. Feel your elbow straightening and your wrist extending. Your hand opens, and your fingertips touch the cool china cup” etc.
3. Practice in the real world. Three listening sessions to one practice session
(Levine, 2009)
Typical mental prac$ce therapy session structure
• 15 minutes – Supplemental or preparatory ac$vi$es – Will assist with performance of designated func$onal task
• 15 minutes – Performance of designated func$onal task with challenge
• 15 minutes – Listening to mental prac$ce recording of designated func$onal task
Page et al 2000, 2001, 2005, 2007
• Method – Tape recorded guided imagery + traditional
therapy vs. audio placebo + traditional therapy – Mentally perform series of tasks
• Ex: reach for cup – 20 min – 1 hr/ day, 2-5 sessions/ week, 4-6
weeks • Results
– Significant improvement in Fugl-Meyer and Action Research Arm Test Scores
Liu et al, 2005
• Mental imagery of specific task + traditional therapy vs. Functional training of specific task + traditional therapy
• Method – Over 3 weeks, trained to perform 3 sets of
daily tasks for 1 hr./ day • Results
– Mental imagery group had higher ADL function than functional training, no difference in Fugl-Meyer scores
Visual Mental Practice Ertelt et al, 2007
• Method – Watch video of upper limb movement &
perform movement VS. watch video of geometric shapes & perform movement
• Results – Significant improvement in video group of
upper limb movement that sustained for at least 8 weeks
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Systematic Reviews • Teasel, 2013 ebrsr.com
– “Mental practice may result in improved motor and ADL functioning after stroke”
• Nilsen, et al., 2010 – “When added to physical practice, mental
practice is an effective intervention. Further research is warranted to determine who will benefit, dosing, and most effective protocols.”
• Wolf & Nilsen, 2015 – “Is an effective intervention to improve UE
function, balance and mobility, and activity participation”
Mirror Therapy
• Uses visual feedback about motor performance to improve rehabilita$on outcomes
• Originally designed for phantom limb pain • Viewing the reflec$on of unaffected arm in the mirror may act as a subs$tute for the decreased or absent propriocep$ve input
Mirror Therapy
• Pa$ent seated close to table with a mirror (35 cm x 35 cm) placed ver$cally
• Involved arm behind mirror, noninvolved in front of mirror
• Complete movements with noninvolved arm • Pa$ent watching movements of noninvolved seeing the reflec$on of the hand mo$on projected over the involved hand
• Pa$ent asked to try to do the same movements with the involved hand while moving the noninvolved
• (Yavuzer et al, 2008)
Mirror Box
Photo from personal collec$on of Chris$ne Griffin. Used with permission.
Mirror Therapy -‐ Evidence
• Yavuzer et al, 2008 – Standard therapy + mirror therapy vs. standard therapy – Mirror therapy group had increased hand func$on and FIM scores compared to standard therapy at 4 weeks 6 months
• Dohle et al, 2009 – Standard therapy + mirror therapy vs. standard therapy – Pa$ents with distal impairment only – Mirror therapy group regained more distal func$on, improved recovery of surface sensibility, s$mulated recovery from hemi-‐neglect
Mirror Therapy -‐ Evidence • Significant improvements in motor function
scores following mirror therapy – Yun et al., 2011 – Thieme et al., 2012 – Noma et al., 2012
• Teasel, 2013 ebrsr.com – 6 RCT’s only – “There is conflic$ng evidence that mirror therapy improves motor func$on following stroke and moderate evidence that it does not reduce spas$city”
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Motor Recovery and Electrical S$mula$on aher Stroke
Low
Low
High
High
Client centered
Task Specific
Cyclic E-stim
EMG- Triggered
E-stim
Functional E-stim
(Page, 2010, used with permission)
Cyclic Neuro Muscular Electrical S$mula$on (NMES)
• Contracts muscles on a preset schedule, does not require active participation
• Goals – Decrease spasticity – Muscle strength – Reduce edema – Improves motor impairment in mild to
moderate stroke (Hill-‐Herman, 2010)
Electro Myograph Generated (EMG) -‐ Triggered
• Must actively move to reach established threshold to “trigger” NMES to activate
• Outcome – Increased function – Decreased motor impairment – Increase ability to concentrate (specifically on
using the affected side of the body) – Enhance behavioral training (active pt
participation) – Marked increase in reaction time – Increase AROM
(Hill-‐Herman, 2010)
EMG – Triggered NMES
• How does it work? – Set s$mula$on intensity and EMG threshold – Electrodes sense trace contrac$on/muscular a\empt – Device rewards pa$ent with s$mula$on – Begin sequence again… (Hill-‐Herman, 2010)
EMG – Triggered NMES Video Exercise & Functional Use
Videos from personal collec$on of Chris$ne Griffin. Used with permission.
Func$onal Electrical S$mula$on (FES)
• Cyclic NMES during functional movements and functional activity
• Goals: – Improve or restore the grasp and manipulation functions
required for typical ADL task – Facilitate neuromuscular reeducation – Regulate muscle tone (decrease spasticity) – Prevent atrophy- muscle strengthening – Initiate and regain voluntary motor functions (muscle
reeducation) (Hill-Herman, 2010, Popovic et al, 2002)
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Func$onal Electrical S$mula$on (FES)
• E-Stim applied to muscles to elicit limb movement in specific sequence during functional tasks
• NMES units, splints, and other supports may be used – Orthoses with embedded electrodes, custom
fit to individual • Patient actively moves limb to engage in
activity (task specific and client centered)
Neuroprosthetic for FES
Photos from personal collection of Christine Griffin. Used with permission.
Video for FES Functional Use & Gravity Eliminated AAROM
Videos from personal collec$on of Chris$ne Griffin. Used with permission.
NMES Evidence –Systematic Review
• “There is strong (Level 1a) evidence that FES treatment improves upper extremity function in acute and chronic stroke” (Teasell, 2013)
• “There is moderate evidence that EMG-triggered NMES is not superior to cyclic NMES” – Majority of studies included acute and chronic stages
of stroke – (Teasel, 2013)
Active Scapular Stability Home Exercise Program
(For patient with low active mobility in upper limb)
Images from Ohio State University Medical Center. Used with permission
Gravity Minimized AAROM – Pre-Functional Level
• For patient with low active mobility in upper limb
• Stability of scapula on thoracic wall with emphasis on upward rotation
• Improves shoulder function and subluxation
Photos from personal collec$on of Chris$ne Griffin. Used with permission.
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Gravity Minimized AAROM – Pre-Functional Level
• Shoulder abduc$on • Elbow flexion and extension
• Supina$on/ Prona$on • Gross grasp
Photo from personal collection of Christine Griffin. Used with permission.
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