Objectives. Definitions. Impac>ng Pa>ent Outcomes Through Strategic Motor Learning Interven>ons Case- Based Approaches for PT & OT 2/22/15

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1 Impac>ng Pa>ent Outcomes Through Strategic Motor Learning Interven>ons Case- Based Approaches for PT & OT Beth Tarduno, MEd, OTR/L, CNDT Objectives Define motor learning & basic motor learning principles. Compare & contrast different motor learning strategies to improve function Integrate motor learning into everyday clinical intervention for improved function. Definitions Motor Control: The study of the nature and control of movement, focusing on understanding movement already acquired Motor Performance Refers to the performance of a skill, but not for the long term Motor Learning: The study and understanding of the acquisition and/or modification of movement or skill for long term. Recovery of Function: Referred to as the reacquisition of movement skills after injury Beth Tarduno, MEd, OTR/L, CNDT 1

2 Motor Learning Neuroplasticity The brain's ability to reorganize itself by forming new neural connections throughout life. Change in neuron function or structure where adjacent cortical areas take over for other areas. Driven by changes in behavioral, sensory, and cognitive experiences or demands. Kleim, J. 2008, Hubbard, I. J., et al How Plasticity Happens Activity is introduced in Challenging Environment ê Changes in Neural Signals ê Reorganization & New Neural Connections ê Changes in Function Requirements for Learning Knowledge of the Goal Practice Motor/Mental/Visual Part/Whole Random/Blocked Interest in the activity Feedback Type & Timing Task specificity/task oriented Challenge/Intensity Beth Tarduno, MEd, OTR/L, CNDT 2

3 Overview of Intervention Assessment Identify Impairments Standardize Test Decide your intervention strategies Retest for results Determine if strategies need to be changed Challenge with improvements Keep focus on function Assessment UE Quick Assessment Motor Learning Individual Task Learning Environment Beth Tarduno, MEd, OTR/L, CNDT 3

4 Knowledge of the Goal Understanding the process the components the sequence the end result Mount, J Pre-Test Hat anempt PRE assessment Practice/Repetitions Research supports increased repetition for learning Motor Mental Visual Beth Tarduno, MEd, OTR/L, CNDT 4

5 Types of Practice Motor (Task-Oriented Training) CIMT or mcimt Repetitive tasks practice Augmented activities (to task oriented) Mirror Therapy Mental Practice/Covert Rehearsal Action Observation (Visual) CIMT vs. mcimt CIMT 1. Daily 6 hours/day 7 days/ week training mcimt min to 3 hrs/day- 2-5 days/week % waking hours restrained 2. Less restrained-- <6 hours/ day 3. Two week intensive 3. two-10 weeks (distributed over time) 4. Intensive repetitive practice 4. Less intensive training over time 5. ADL s, repetitive, shaping 5. ADL s, repetitive, shaping 19/20 studies = + findings on at least one outcome measure on CIMT & mcimt 6/7 studies = + ADL s and participation All studies found maintained gains in UE function over 6 months No significant difference between the groups More compliance with mcimt Nilsen, D.M., et al 2015 Beth Tarduno, MEd, OTR/L, CNDT 5

6 Repetitive Task Practice Includes: Goal directed individualized tasks Task-specific movements Task relate movements Repetitive Task Practice Review of 17 articles: 13 looked at improvement in UE functionalall improved 9 looked at improvement in balance & mobility- all improved 4 studies looked at activity/participation- all improved Task Specific Task Specific: For retention (performance) Variety: For generalization and retention Increase challenge-point for learning and retention Allow errors for problem solving for transfer Give them choices in the activity in order to appropriately challenge the learner at a desirable level of functional task difficulty, the practice environment should change as the learner s skill level changes. Iman, F., Valizade, R., 2011 Beth Tarduno, MEd, OTR/L, CNDT 6

7 Mirror Therapy Affected extremity is hidden behind a mirror Stronger extremity performs simple to complex movements &/or functional activities Encourage movement of the affected extremity Sensory cortex integrates with motor cortex Mirror Therapy- Evidence 15 minutes 2X/day 6 days/week (Lancet) Subjective feedback + from patients for improvement Two neurologists graded movement = all + One hour/day 5 days/week (Michielsen, et al) FM assessment baseline & 6-months fmri- baseline & 6 months- activation of primary motor cortex Mirror Therapy- Evidence Level I study- 25 min 2X/day 5X/week X 4wks (Lee, Cho, & Song, 2012) FMA, Brunnstrom stages, and Manual Function Test All tests + outcomes Authors concluded mirror therapy is effective in UE and function recover Review of 14 studies/ 567 individuals/ RCT s and randomized cross-over trials (Theime, et al 2012) + for motor function, ADL s, and visual spatial neglect Evidence + for adjunct to normal rehabilitation of stroke Beth Tarduno, MEd, OTR/L, CNDT 7

8 Mental Imagery Cognitively rehearsing a physical skill in the absence of actual movements Combined with traditional task specific/oriented practice Studies: 3/7 studies + for improved UE function and activity/ participation Supportive evidence to implement as an adjunct to traditional therapy Mental Practice Page (2007) compared mental practice (MP) +physical practice (PP) to PP plus a placebo of relaxation exercises (PI) 36 patients randomly assigned (mean 3.6 yrs post CVA & moderate motor deficits) 30 minutes PP/week X 6 weeks- all patients 30 minutes/week PP + MP or PP +PI group Mental &/or Physical Practice Functional Task Practiced Reaching for and grasping a cup or object Turning a page in a book Proper use of a writing utensil Beth Tarduno, MEd, OTR/L, CNDT 8

9 Mental &/or Physical Practice PP + MP improved in Fugl Meyer and ARAT hnp://stroke.ahajournals.org/content/38/4/1293.long#t3 Page, S. (2007) Hypothesis about Mental Practice Motor improves due to the learner Thinking about what can be tried Predicting consequences based on practice Integrating the sequence of the task Activating mirror neurons Mental Practice Video Beth Tarduno, MEd, OTR/L, CNDT 9

10 Visual (Action) Observation Patients watched 6 minute video of an activity prior to actual practice Simple tasks (moving tissues between hands) to complex (manipulating cup, turning on faucet) fmri- + activation of frontal & parietal lobes during observation Improvement thought to be due to activation of mirror neurons Ertelt, D, et al (2007) Learning from Others Task= free weight squat lift, 30# bar weight w/ squats McCullagh, P., 1997 Supported by MaNar, A.A., 2005 Visual Learning Watching videotapes by themselves hindered learning and did not contribute to learning Without guidance there is too much information There may be lack of knowledge of what is important May be too distracting to watch themselves.. Critical for distinct directions with voice over Beth Tarduno, MEd, OTR/L, CNDT 10

11 How about a Challenge? Monkey study: Press lever to avoid shock, then added a sound to recognize tone to avoid shock 1) Any tone- press lever 2) A tone in a specific range- press lever *** 3) Specific tone- press lever *** Area of cortex to process sound increased, but not when the task increased in unsuccessful range Kleim, J.A., 2014 Challenge Monkey study: - Really easy - No change in cortical structure - Really hard No change in cortical structure - Sweet Spot - Change in cortical structure Just Right Challenge Kleim, J.A Shumway- Cook, A., WoollacoN, M.H., 2001 Challenge/Summary Reaching Interven>on.mp4 Beth Tarduno, MEd, OTR/L, CNDT 11

12 Motor Practice: Cortical Changes in Mapping Monkey Study: Day 1- Maps got larger- 400 reps, rested Day 3- Maps were smaller but with training increased again with 2,000 reps Day 8- Maps stayed large total 6,000 reps * Day 3-8 is when they maxed out * Healthy brain reorganized in 8 days due to repetition * May help us to determine LOS and intensity (Kleim, 2014) Strength Practice Kleim, et al (2014)- Strength training of rats Spaghetti pieces tested for amount of spaghetti strands they could break off 4-5 pieces = 1 Rep Max Practiced 10 sets of 10-4X/day X 4 weeks Increased to breaking off 13 strands Strength training= no change in cortical mapping, but increased blood vessels Strength Training 15 articles reviewed- Level I research All provided evidence regarding effectiveness of strength/exercise UE function (11/15) Balance & mobility (8/11) Improved activity/participation (11/13) Nilsen, D.M., et al 2015 Beth Tarduno, MEd, OTR/L, CNDT 12

13 Conditions of Practice Distributed versus Massed Random versus Block Variable versus Constant Specific versus contrived/simulated Distribution versus Massed Describes sequence of practice & rest times Distributed Practice: Rest time between trials is equal to or greater than practice time 10 seconds practice to 10 second or > rest time Massed Practice: Rest time between trials is less than practice time 10 seconds practice to 5 second rest Distribution versus Massed Meta-analysis reviewed 116 studies distributed practice = better performance during acquisition & better retention Better performance during acquisition is believed to be due to resting from fatigue Better retention may be better due to ability to intrinsically integrate the information and reminisce on the performance. Donovan, J.J., Radosevich, D.J.,(1999) Beth Tarduno, MEd, OTR/L, CNDT 13

14 Distribution versus Massed Considerations Patient can not have as many practice trials with distributed if the treatment time is limited (30 min session) When there is limited time, massed practice allows for more practice. If fatigue doesn t occur, massed practice may be better Random vs. Blocked Practice Blocked: Practicing one task repeatedly, then moving on to the next task. TTTTTTTTPPPPPPSSSSSSS Random: Practicing tasks in random order. TPSTSPPTSPSSTSTPPSSTPP Random vs. Blocked Practice Blocked is better for performance, but random is better for learning (Shea & Morgan, Wright, 2004) Blocked practice is better for populations that have difficulty learning, such as Parkinson s Disease. (Lin, 2007) Beth Tarduno, MEd, OTR/L, CNDT 14

15 Constant vs. Variable Practice Constant: Practicing one variation of one task Example: Sit to stand from the same wheelchair Variable: Practicing multiple variations of one task Example: Sit to stand from many surfaces Constant vs. Variable Practice Constant: Best for individuals with Alzheimer s Disease or cognitive deficits. (Dick, 2003) Variable: Best for healthy adults learning a novel task. (Shea & Kohl, 1991). Best for children learning skills even more than adults. (Shapiro and Schmidt, 1989) What it takes to be an expert? 3 million cigars to be an expert at age 60 s 1.6 million bats hit 750,000 pitches (Kleim, J. 2014) Beth Tarduno, MEd, OTR/L, CNDT 15

16 Repetitions Repetition alone, without usefulness or meaning in terms of function, is not enough to produce increased motor cortical representations Consider circuit training- stations set up in the clinic Inform patients how the activity will help to achieve the goal Bayona et al, (2005) Post Test Hat interven>on- POST Summary Practice is necessary for learning motor skills Retention improves with practice and challenging tasks Adjuncts to traditional therapy Mental practice Visual observation Mirror therapy Knowing the goal and components is critical Keep the just right challenge in mind Implement evidence based into your practice Keep the tasks functional Beth Tarduno, MEd, OTR/L, CNDT 16

17 References Arbersman, M, Lieberman, D, Berlanstein, D.R., (Jan/Feb 2015) Method for the Evidence-Based Reviews on Occupational Therapy and Stroke. AJOT, 69 (3), p p5. Bayona NA, Bitensky J, Salter K, Teasell R (2005). The role of task-specific training in rehabilitation therapies. Topics in Stroke Rehabilitation 12: DOI: / BQM5-6YGB-MVJ5-WVCR Donovan, J.J., Radosevich, D.J., (1999), A meta-analytic review of the distribution of practice effect: Now you see it, now you don t. J Appl Physiol, 84 (5), Ertelt, D., Small, S., Solodkin, A., Dettmers, C., McNamara, A., Binkofski, F., Buccino, G., (2007), Action observation has a positive impact on rehabilitation of motor deficits after stroke. Granados C., and Wulf G., (2007) Enhancing motor learning through dyad practice: contributions of observation and dialogue. Res Q Exerc Sport, 78(3): Hubbard, I.J., Parson, M.W., (2009), Task-specific training: evidence and translation to clinical practice. Occup. Ther. Int 16 (3-4): DOI: /oti.275 Iman, F., Valizade, R., (2011), Systematically increasing contextual interference is beneficial for learning single task. Retrieved from Beth Tarduno, MEd, OTR/L, CNDT 17

18 References Kleim,J., (2014, April). Neural Plasticity: Foundation for Neurorehabilitation. Instructor group meeting. Lecture conducted from Chicago, IL. Kleim, J.A., Jones, T.A., (Feb. 2008), Journal of Speech Language, and Hearing Research. Vol 51, S225- hnps:// Lin, C.H. (J), Sullivan, K.J., Wu, A.D., Kantak, S., Winstein, C.J., (2006). Effect of Task Practice Order on Motor Skills Learning in Adults with Parkinson Disease: A Pilot Study. Phys Ther. 28(9) Retrieved from Mattar A.A. Gribble,P.L., (2005), Motor learning by observing. Neuron &;46 (1): McCullagh, P., and Meyer, K.N., (1997). Learning Versus Correct Models: Influence of Model Type on the Leaning of a Free-Weight Squat Lift. Res Q Exerc Sport, 68. Retrieved from References Mount, J., (2014, February) Integrating Motor Learning Research into Clinical Practice: Feedback and Conditions of Practice. Lecture conducted from Thomas Jefferson University, Pittsburgh, PA. Nilsen, D.M., Gillen, G., Geller, D., Hreha, K., Osei, E., Saleem, G.T., (Jan/Feb 2015). Effectiveness of Interventions to Improve Occupational Performance of People With Motor Impairments After Stroke: An Evidence-Based Review. AJOT 69 (3) p p9. Page S.J., Levine, B.A., Leonare, A., (2006). Mental Practice in Chronic Stroke Stroke. Retrieved from Schmidt, R.A. and Lee, T.D., (2011), Motor Control and Learning 5 th Edition, In motor learning, is mental practice as effective as physical practice? Retrieved from Shumway-Cook, A., Woollacott, M.H., (2001). Motor Control Theory and Practical Applications. Lippincott Williams & Wilkins, Baltimore, MD. Beth Tarduno, MEd, OTR/L, CNDT 18