Jim JensenErgoterapeut

FOTT InstruktørMaster i rehabilitering

Fagligt Netvæk i Ergoterapeutforeningen: Senhjerneskade

19.11.2010

Spejlneuroner og praksis

Baggrund3 år i Tyskland fra 1996-1999

5 år på Kurhus, Dianalundfra 1999-2004

2004 - nu på Hammel Neurocenter

Med en enkelt afstikker til Neuroklinik i Århus2005-2006

Inspiration:Motivation og glæde

Kay CoombesTheo Mulder / movement science Patricia Davies: Skridt for skridt Bernstein: DexterityAntonio Damasio: Descartes´ fejltagelse Ramachandran: Phantoms of the brain

Studietur til University of Southern California / USC i 2007

USCAktivitetsvidenskab / occuptional scienceSanseintegration / Jean AyresNeurovidenskab / neuroscience

Damasio og Liza Aziz Zadeh

Spejlneuroner

IndholdspunkterSpejlneuronsystemet

Spejlboks

Spejlterapi

Mental imagery

Motor imagery

Gruppeterapi

Omgivelserne

EEG studie - betydningsfulde stimuli i neurorehab.

Hjernen

100 billioner neuroner som hver indgår i 1000 – 10.000 forbindelser

UndersøgelserFMRI (Funktionel Magnetisk Ressonans Imaging)

EEG (Elektro – EncephaloGrafi)

TMS (Transkraniel Magnetisk Stimulation)

PET (Positron Emission Tomografi)

OpdagelsenUniversitetet i Parma, 1989 (Fadiga, Rizzolatti)- Single celle optagelser af neuroner I område F5.- Premotor area i makak aber.-Neuroner koder for gribe bevægelser.- Også neuronal fyring når aben kun observerer forskeren håndtere objektet.- Spændende nyt fund:- Motor neuroner (involveret i udførelse afhandling) er også involveret i perceptionenaf andre menneskers motoriske handlinger.

SpejlneuronerAktiveres når bevægelse udføres eller observeres. (Gallese et al. 1996; Rizzolatti et al. 1996; Ferrari et al. 2003)Ligegyldig hvordan målet opnåes.(Umiltàet al. 2008)Aktiveres når bevægelsen kun kan ses fra hints(Umiltàet al. 2001)Aktiveres når bevægelsen kun kan høres(Kohler et al. 2002)Indeholder en ”abstrakt” repræsentation for handling.Støtter en direkte form for handlings forståelse.

Menneske vs. abe Lokalisationen af spejlneuroner i mennesket er meget lig detsom er fundet i aber, men der er funktionelle forskelle.

1. Ved mennesker bliver SNS også aktiveret ved ikke–objektrelaterede motoriske bevægelser, som også mimiskehandlinger.

2. Det menneskelige SNS er tunet til timingen af den motoriskebevægelse, altså kodende den målrettethed der er over bevægelsen men også de temporale aspekter af den individuelle handling ledende til målet. (Rizzolatti & Craighero 2004; Rizzolatti & Fabbri-Destro2008).

Spejlneuroner og sansning

Deling af taktile stimuli

Deling af visuelle stimuli (spejlboks)

Parietofrontale spejlneuron system

Kortile områder relateret til parietofrontal spejl system responderer tilforskellige typer af motoriske handlinger. Gul indikerer transitive distalebevægelser. Lilla: række bevægelser. Orange: Brug af redskaber. Grøn: intransitive bevægelser. Blå: en del af superior temporale sulcus (STS) somreagerer på bevægelser i overekstremiteten. IFG indikerer inferior frontal gyrus; IPL, inferior parietal lobule; IPS, intraparietal sulcus; PMD, dorsalpremotor cortex; PMV, ventral premotor cortex; og SPL, superiorparietal lobule.

STS

IPL

IFG

IPS

PMD

PMV

SPL

Spejlneuroner og emotioner

Anatomical locations of the motor and somatosensory components of simulation. (a) Lateral view of the human brain with the location of the ventral premotor cortex (BA6/BA44) and the inferior parietal lobule (IPL). (b) Lateral view showing the location of the primary and secondary somatosensory cortex ...J. A. C. J. Bastiaansen, et al. Philos Trans R Soc Lond B Biol Sci. 2009 August 27;364(1528):2391-2404.

Spejlneuroner og emotioner

Anatomical locations of affective components of simulation. (a) Sagittal view of a human brain with the location of the anterior cingulate cortex (ACC). (b) Coronal view of a human brain showing the location of the insula and the amygdala.From:Philos Trans R Soc Lond B Biol Sci. 2009 August 27; 364(1528): 2391–2404.

Spejlneuroner og emotionerEt stort studie af mennesker med hjerneskade har vist at skader i det højre sensomotoriske cortex (centreret omkring den mest ventrale del af sensomotorisk cortex, hvor ansigtet er repræsenteret) skader evnen til at erkende emotioner fra et visuelt præsenteret ansigt.

(Adolphs et al. 2000).

Aktivering af sensomotoriske repæsentationer af ansigtet erafgørende for visuelt at kunne genkende følelser i andres ansigter.

V.S. Ramachandran

“I predict that mirror neurons will do for psychology what DNA did for biology: they will provide a unifying framework and help explain a host of mental abilities that have hitherto remained mysterious and inaccessible to experiments.”

Imitation og empati.

Lære bevægelser / handlinger

og forstå hvad andre gør.

Udvikling gennem tidenHjernen nuværende størrelse / form opnået for 3-400.000 år siden

For 100.000 år siden skete der et spring frem i ft.

Brug af ild

Brug af værktøj

Brug af huler/hytter

Sprog

Tese om udvikling/ modning af SNS (theory of the mind)

Neurorehabil Neural Repair. 2010 Jun;24(5):404-12. Epub 2010 Mar 5.The mirror neuron system: a neural substrate for methods in stroke rehabilitation.Garrison KA, Winstein CJ, Aziz-Zadeh L.Motor Behavior and Neurorehabilitation Laboratory, Division of Biokinesiology and Physical Therapy, Brain and Creativity Institute, University of Southern California, Los Angeles, CA 90089-9006, USA. kgarriso@usc.eduAbstractMirror neurons found in the premotor and parietal cortex respond not only during action execution, but also during observation of actions being performed by others. Thus, the motor system may be activated without overt movement. Rehabilitation of motor function after stroke is often challenging due to severity of impairment and poor to absent voluntary movement ability. Methods in stroke rehabilitation based on the mirror neuron system--action observation, motor imagery, and imitation--take advantage of this opportunity to rebuild motor function despite impairments, as an alternative or complement to physical therapy. Here the authors review research into each condition of practice, and discuss the relevance of the mirror neuron system to stroke recovery.

FremtidenHvad ligger foran os af nye, men også udfordrendespørgsmål?

Hvad er det at spejlneuroner gør for os?

Hvilken forskel er der i funktionen på spejlneuronerne i de forskellige hjerneområder?

Hvordan interagerer spejlneuroner i de forskelligehjerneområder med hinanden?

Hvordan bliver handlinger en del af os eller andre, og hvilkeroller spiller anti – neuroner i denne funktion?

Terapi – individuel / grupper

Spejling i forhold til andre medpatienter / raske.

Fordele – ulemper.

Rollemodeller – Patient / terapeut.

Brug af følelser – relationer.

Eksemplificere bevægelser.

Før – under – efter.

OmgivelserMulighed for spejling

Af andre

Af sig selv

Mulighed for aktiviteter

Billeder af mennesker i aktivitet

Motor imageryArch Phys Med Rehabil. 2003 Jul;84(7):1090-2: Performance of the paretic limb improved after the imagery intervention, indicated by increases in assessment scores and functionality and decreases in movement times. The improvements over baseline performance remained stable over a 3-month period (8 subjects)

Neuroimage. 2007;36 Suppl 2:T164-73 : A significant improvement of motor functions in the course of a 4-week treatment, as compared to the stable pre-treatment baseline, and compared with a control group have been found. The improvement lasted for at least 8 weeks after the end of the intervention (8 subjects)

Mental imagery

Motor recoveryLancet Neurol. 2009 Aug;8(8):741-54.Motor recovery after stroke: a systematic review.Langhorne P, Coupar F, Pollock A.Stroke Therapy Evaluation Programme, Academic Section of Geriatric Medicine, Cardiovascular and Medical Sciences Division, Royal Infirmary, Glasgow, UK. p.langhorne@clinmed.gla.ac.ukAbstractLoss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. In this Review, we aimed to provide an overview of the available evidence on interventions for motor recovery after stroke through the evaluation of systematic reviews, supplemented by recent randomised controlled trials. Most trials were small and had some design limitations. Improvements in recovery of arm function were seen for constraint-induced movement therapy, electromyographic biofeedback, mental practice with motor imagery, and robotics. Improvements in transfer ability or balance were seen with repetitive task training, biofeedback, and training with a moving platform. Physical fitness training, high-intensity therapy (usually physiotherapy), and repetitive task training improved walking speed. Although the existing evidence is limited by poor trial designs, some treatments do show promise for improving motor recovery, particularly those that have focused on high-intensity and repetitive task-specific practice.

Spejlboks

Ramachandran, 1998 (phantoms of the brain)

Baggrund for spejlboksHjernens plasticitet som bl.a. er set ved amputationer

Fantomoplevelser og smerte.

Refleksdystrofi / smerte (McCabe et al) og spejlterapi.

Hemiplegi.

Sensomotorisk cortex

Sensoriske proportioner

Spejlterapi

Neurorehabil Neural Repair. 2010 Nov 4. [Epub ahead of print]Motor Recovery and Cortical Reorganization After Mirror Therapy in Chronic Stroke Patients: A Phase II Randomized Controlled Trial.Michielsen ME, Selles RW, van der Geest JN, Eckhardt M, Yavuzer G, Stam HJ, Smits M, RibbersGM, Bussmann JB.AbstractOBJECTIVE: To evaluate for any clinical effects of home-based mirror therapy and subsequent cortical reorganization in patients with chronic stroke with moderate upper extremity paresis.METHODS: A total of 40 chronic stroke patients (mean time post .onset, 3.9 years) were randomly assigned to the mirror group (n = 20) or the control group (n = 20) and then joined a 6-week training program. Both groups trained once a week under supervision of a physiotherapist at the rehabilitation center and practiced at home 1 hour daily, 5 times a week. The primary outcome measure was the Fugl-Meyer motor assessment (FMA). The grip force, spasticity, pain, dexterity, hand-use in daily life, and quality of life at baseline-posttreatment and at 6 months-were all measured by a blinded assessor. Changes in neural activation patterns were assessed with functional magnetic resonance imaging (fMRI) at baseline and posttreatment in an available subgroup (mirror, 12; control, 9).RESULTS: Posttreatment, the FMA improved more in the mirror than in the control group (3.6 ±1.5, P < .05), but this improvement did not persist at follow-up. No changes were found on the other outcome measures (all Ps > .05). fMRI results showed a shift in activation balance within the primary motor cortex toward the affected hemisphere in the mirror group only (weighted laterality index difference 0.40 ± 0.39, P < .05).CONCLUSION: This phase II trial showed some effectiveness for mirror therapy in chronic stroke patients and is the first to associate mirror therapy with cortical reorganization. Future research has to determine the optimum practice intensity and duration for improvements to persist and generalize to other functional domains.

Disabil Rehabil. 2009;31(26):2135-49.Systematic review of the effectiveness of mirror therapy in upper extremity function.Ezendam D, Bongers RM, Jannink MJ.Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.AbstractPURPOSE: This review gives an overview of the current state of research regarding the effectiveness of mirror therapy in upper extremity function.METHOD: A systematic literature search was performed to identify studies concerning mirror therapy in upper extremity. The included journal articles were reviewed according to a structured diagram and the methodological quality was assessed.RESULTS: Fifteen studies were identified and reviewed. Five different patient categories were studied: two studies focussed on mirror therapy after an amputation of the upper limb, five studies focussed on mirror therapy after stroke, five studies focussedon mirror therapy with complex regional pain syndrome type 1 (CRPS1) patients, one study on mirror therapy with complex regional pain syndrome type 2 (CRPS2) and two studies focussed on mirror therapy after hand surgery other than amputation.CONCLUSIONS: Most of the evidence for mirror therapy is from studies with weak methodological quality. The present review showed a trend that mirror therapy is effective in upper limb treatment of stroke patients and patients with CRPS, whereas the effectiveness in other patient groups has yet to be determined.