Massed practice in neurological rehabilitation

Johan Lambeck; in cooperation with Marcel Hulselmans, Edina Sziráki, Péter Pribély,

Nico van den Beukel, Joost Spelt

lambeck@freeler.nl

Programme

•  Introduction Johan Lambeck

•  Overview of treadmill research and applications Marcel Hulselmans

•  Explanation of the possibilities of the Aquawallgym Edina Sziráki

•  A circuit in the pool with various pieces of equipment and activities „freely“ in the water Johan Lambeck, Marcel Hulselmans, Edina Sziráki, Péter Pribély, Nico van den Beukel, Joost Spelt

Motor (re)learning in neurology:

How to rewire the brain

•  What is motor (re)learning? •  A theoretical concept •  Principles •  Massed practice •  Enriched environment •  Why water?

Motor learning = •  Achieving a "relatively permanent” change towards

skilled motor behavior, resulting from practice, also capable of error-detecting and responding to the

constraints of the environment (Schmidt & Lee 1999)

•  An effective way of learning is by offering variability of skill performance by changing context and (bio)mechanical constraints (Schmidt and Lee)

Practice

– Achievement depends on structure (quality and quantity) of practice and feedback as well on the interaction between the person, the task and the environment •  Dynamic Systems Model / DSM (Newell 1986)

DSM

Motor control

Task

Envi

ronm

ent

Newell 1986:

The specific constraints of the environment can therapeutically influence the patient‘s motor behavior

The pool

To prevent or to change these: Increase movement frequency and stress the neuromotor system. The system gets instable and possibly adapts /trains. Enrich the environment in order to stimulate the neuromotor flexibility

Therapy >> distributed massed practice in an enriched evironment

Bad habits In neurology, specific motor behavior solutions will appear and persist a „bad habit“ (Beek, 2012).

Distributed massed practice

•  An intervention with repetitive practice as the primary therapeutic factor, with distributed rest periods (Taub 2001, Murray 2003)

–  A known example is constraint induced movement therapy

•  Goal: functional cortical (brain) reorganization according to Taub & Nudo by e.g synaptosis, dendritogenesis and angiogenesis

Research

–  increased somatosensory activity in the same and adjacent maps Beekhuizen 2005, 2008

» 2 h, 4 days/wk continuous repetition of tasks in 5 categories, 25 min per category (incomplete SCI handfunction

–  Large (ss) improvements in various walking - and balance tests Marklund 2006

– chronic post-stroke patients 6 h, 5 days/week, 2 weeks. Random choice of cycling, pool training, functional strength training in different start positions (sitting down, stand up and lay down), weight-bearing in different directions, stair training without use of banisters, indoor walking/outdoor walking on uneven surfaces.

Research: case study

– Sign. results in (anticipatory) balance with less falls and more symmetrical weight-bearing

–  Vearrier & Shumway-Cook 2005: 1 patient post-stroke – 6 h/day, 5 days/week, 2 weeks. Contents:

•  functional mobility: ambulation and upright static and dynamic balance tasks

•  addressing impairments such as limitations in strength and ROM. •  Subjects’ daily regimen consisted of 70% functional training, 20%

impairment related intervention, 5% disability level activities, and 5% intermittent rests

•  Equipment that also was used: bicycle, treadmill, obstacles

Contextual interference

•  Contextual interference is a technique that involves making the practice environment more difficult by having learners practice several skills interchangeably and randomly

•  Random (= unpredictable) variability in the form of

irrelevant movement components, necessary for good performance

– Always some minutes for every skill, but sequence at random

Stochastic resonance W. Schöllhorn (2010)

•  There is no ideal movement and we cannot correct toward that ideal movement

•  Mistakes are important: these give differences with information about the best way to perform a task

•  Stochastic resonance = adding bias can show a below-threshold signal > variations in environment and task make the central nervous system react. This cns response continues after the actual training.

Environment enrichment

•  Refers to conditions that facilitate enhanced sensory, cognitive, affective and motor stimulation, Nithianantharajah & Hannan 2006

•  Environmental enrichment stimulates the hippocampus to produce BDNF = brain derived neurotrophic factor Sao 2010

– BDNF production is also augmented during bicycling in water by patients with Multiple Sclerosis Bansi 2012

Keywords:

Somato-sensory stimulation

Modulation of attention

Exploratory movements

Practice needs to be

•  Challenging / demanding /motivating

•  Repetitive, yet variable

•  Attention taking

•  Arousal stimulating

Therapy

•  Distributed massed practice with contextual interference in an enriched environment by random application of variable, challenging, arousing, motivational and attractive exercises.

•  Would a massed practice set-up in the pool also reach the above mentioned idea?

Why water in (early) neuro-rehab?

•  Slow instability – water as a perceptual reference surface –  The patient has to react

•  Freedom of movement – High dose of information and motor output

•  Distributed massed practice

– Patient can be dynamic, but grade intensity: •  Easier to run, jump, sneak, walk and talk •  important also for the cardiovascular/pulmonal

systems

The environment provides

•  Support – Hands-free: space between patient and therapist =

independence –  Less force needed to elicit muscle activity

•  Safety – No risk to fall, but still a challenge to balance –  Time to think and to react

•  Input to the CNS changes – We like it: Water = fun and motivates

The pool

•  A circuit in the pool with various pieces of equipment and activities „freely“ in the water

– Pooltrack treadmill – Underwater bicycle – Obstacle course – AquawallgymTM

– Stations with picto‘s about Halliwick activities – Aquatwister – Aquastrider – Aquawalker

Aquagym: aquaclimber, aquastrider, aquatwister

Free Halliwick like exercises

Thank you for your attention

and let‘s continue