Course Objectives. Motor Learning Rehabilitation 2/21/2015. Mowder Tinney

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1 Impacting patient Outcomes Through Strategic Motor Learning Interventions: Case Based Approaches for Both PT & OT J.J. Mowder Tinney PT, PhD, NCS, C/NDT, CSRS Course Objectives 1. Define motor learning and basic motor learning principles. 1. Compare and contrast different motor learning strategies to improve function. 1. Integrate motor learning into everyday clinical interventions. 2 Motor Learning Rehabilitation For 25 years the area of motor learning has been working on translating the science for rehabilitation (Fisher, 2014 JNPT) There has been an exponential rise in the articles that you can find on Pubmed incorporating the terms motor control and rehabilitation Fisher BE, Morton SM. From Motor learning to Physical Therapy and Back Again: The state of the art and science of motor learning rehabilitation research. JNPT.2014;38: Mowder Tinney

2 Bridging the Gap Understanding the basic theory and definitions is important but then the knowledge has to be translated to bridge the research/clinician gap. How can a task be structured to optimize a movement strategy? When teaching a motor skill what types of cueing can be given to provide the best learning environment? 4 Motor Learning Strategies We already talked about task specificity, repetition, intensity, part/whole and random/blocked practice. I am going to focus on Self control cueing, External focus of attention, Extrinsic feedback, and Motor adaptation strategies We will look at ways in the case of how to combine some of these concepts DON T FORGET MOTIVATION IS KEY If the activity doesn t mean anything to them and is not functional (tapping dots on floor, being given perturbations in sitting, sitting marching, etc). How do those things challenge and motivate them to be functional? Mowder Tinney

Learning Goal oriented Skill acquisition is shaped by the specific tasks that are used to challenge the patient Goals of the therapist Choose appropriate task Structure the environment Progressively

3 Learning Goal oriented Skill acquisition is shaped by the specific tasks that are used to challenge the patient Goals of the therapist Choose appropriate task Structure the environment Progressively increase complexity Vary the task and try new tasks James Gordon, Learning Performance Distinction The goal is to accomplish a relatively permanent change in the capability of learning versus a short term temporary change. The distinction is noted between the observed behavior during practice (motor performance) and sustaining the activity over time due to practice (motor learning) Kantak SS, Winstein CJ. Learning performance distinction and memory processes for motor skills: A focused review and perspective. Behavioural Brain Research.2012;228: Mowder Tinney

4 Intensity Significant relationship between: Stepping practice during therapy/training Dose and Response Improvements in daily stepping following therapy/training Moore JL, et al. Locomotor training improves daily stepping activity and gait efficiency in individuals poststroke who have reached a plateau in recovery. Stroke 2010;41: If it is intense enough, specific enough, and goal oriented, then you do not need fancy equipment. Carol Richards PhD, DU, PT 11 Are Current Intensities Enough? Study of patients of PT and OT between 2 14 weeks post stroke HR monitored to assess amount of time spent training cardiorespiratory system Found if it was present the aerobic component of typical physiotherapy session lasted less than 3 minutes. Study suggests physiotherapy is not intensive or targeted enough to have a training effect» Mackay Lyons MJ and Makrides L. Exercise capacity early after stroke. Archives of Phys Med and Rehab. 2002;83(12): Mowder Tinney

5 Considerations for Challenges Joints included Plane of motion Lever arm Muscle contraction Resistance direction & intensity Task speed Environment Sensory input Error 13 Where Do We Start? Start with understanding the underlying impairments so you choose the best strategies THEREFORE understand normal movement first! Normal Movement First APTA VISION Transforming society by optimizing movement to improve the human experience. What do you remember as the movements for sit to stand to be successful?? What ranges do you need?? When do you need strength to kick in?? Mowder Tinney

Sit to Stand Pre Extension Phase This phase requires active proximal control but is about movement Need trunk to stay neutral with slight thoracic extension, neutral pelvis progressing to anterior

6 Sit to Stand Pre Extension Phase This phase requires active proximal control but is about movement Need trunk to stay neutral with slight thoracic extension, neutral pelvis progressing to anterior tilt, and hip flexion These motions shift the weight forward and provide weight bearing through LEs Tibias need to be able to translate forward with knees flexed until hips lift off the mat What Can Limit Forward Progression of the Tibia? Mowder Tinney

Extension Phase Need symmetrical firing of extensor muscles to provide the extension moment of hip/trunk and knee May have enough strength but if not properly aligned can see compensations like

7 Extension Phase Need symmetrical firing of extensor muscles to provide the extension moment of hip/trunk and knee May have enough strength but if not properly aligned can see compensations like Leaning onto good side Rotating in trunk Pushing up heavily with UE Potential Impairments So. What are some potential impairments (things you would find during your examination) that would limit sit to stand?? WHAT WOULD YOU DO?? Mowder Tinney

Interventions Facilitate Movement NDT Facilitation Facilitate Error Adjust cues Increase motivation Increase Challenges and Intensity

consciously aware of how they are performing External Focus Directed toward the effect of the movement on the environment, or the end goal Count

Internal and external focus of attention during gait re education: An observational study of physical therapist practice in stroke rehabilitation.

8 Interventions Facilitate Movement NDT Facilitation Facilitate Error Adjust cues Increase motivation Increase Challenges and Intensity Somatosensory Vestibular Weightbearing Speed Cueing Internal Focus Directed toward components of the body movement where the learner will be consciously aware of how they are performing External Focus Directed toward the effect of the movement on the environment, or the end goal Count how many steps it takes to walk 25ft have them count out loud, then ask to do in 22 steps, then 18. Johnson L et al. Internal and external focus of attention during gait re education: An observational study of physical therapist practice in stroke rehabilitation. Phys Ther. 2013;93(7): Retrain isolation of knee flexion with hip extension Right side impaired: 2 lb weight on right ankle, ball behind for external cue to kick 24 Mowder Tinney

9 Self Control Providing the patient some aspect of control during an intervention enhances motor learning. When possible limit externally imposed conditions and have the patient adjust the situation parameter Let them determine the distance, the repetitions, how to increase challenge Andrieux M, Danna J, Thon B. Self control of task difficulty during training enhances motor learning of a complex coincidence anticipation task. Research quarterly for exercise and sport. 2012;83(1): Self Controlled Practice Suggest a deeper processing of relevant information when allowed to adjust training parameters and take charge of their own learning process resulting in more active involvement and increased effort invested Chiviacowsky S, Wulf G, Lewthwaite R, Campos T. Motor learning benefits of self controlled practice in persons with Parkinson s disease. Gait and Posture.2012;35: Increased Autonomy In addition, allowing increased opportunities for selfcontrol may allow increased autonomy. Increased autonomy has resulted in increased intrinsic motivation and engagement with an improved perception of competence. Overall self control group participants demonstrate more effective learning. Chiviacowsky S, Wulf G. Self controlled feedback: Does it enhance learning because performers get feedback when they need it? Research quarterly for exercise and sport. 2002;73(4): Mowder Tinney

10 Extrinsic (Augmented) Feedback This type of feedback is given in addition to intrinsic feedback by an outside artificial means. KP (Knowledge of Performance) is externally provided feedback that is focused on the quality of the movement. KR (Knowledge of Results) is also externally provided and is focused on the outcome or goal of a skill. 28 Reinforcement of Walking Speed Providing specific outcome measure results to patients can result in improved outcomes. For instance, the SIRROWS trial found that a single daily bout of feedback about performance for that day s walking speed led to significantly faster speeds (.19m/s difference) at discharge compared to well matched controls who did not receive feedback. Dobkin BH, etal. International randomized clinical trial, stroke inpatient rehabilitation with reinforcement of walking speed (SIRROWS), improve outcomes. Neurorehabil Neural Repair. 2010;24: Fritz, S. and M. Lusardi (2009). "White paper: "walking speed: the sixth vital sign"." J Geriatr Phys Ther 32(2): Mowder Tinney

11 Think Basic Use an outcome measure that targets a specific behavior and a chart to communicate the changes to the patient. GAIT SPEED TIMED SIT TO STAND TIMED SUPINE TO SIT ERROR How do you get a patient to correct abnormal movement patterns that the nervous system may not perceive as erroneous or requiring correction? Need to perturb the system (theraband, weights on ankle, split belt treadmill, size of objects) if one can develop a capability to detect one s own errors, then the learner can practice without a teacher or a coach. Schmidt R. Motor Schema Theory After 27 Years: Reflections and Implications for a New Theory. Research Quarterly for Exercise and Sport. 2003;74(4): Motor Adaptation Significant errors seen in the beginning because the CNS does not correctly predict the new situation Once the CNS has adjusted and the challenge is withdrawn, error will occur in the opposite direction Looking for the after effects Reisman DS, Bastian AJ, Morton SM. Neurophysiologic and rehabilitation insights from the split belt and other locomotor adaptation paradigm. Phys Ther. 2010;90: Mowder Tinney

making him overcompensate to get the leg neutral.

12 Video Summary Resistance of the TheraBand was placed to exaggerate the gait deviation. Since he is externally rotating and abducted then he theraband pulls his leg into that motion making him overcompensate to get the leg neutral. They must have some strength to be successful! Need to increase recruitment, so we challenge them for motor adaptation 34 Mowder Tinney

13 Segment I Patient Case Patient is a 69 year old man who was having complaints of left upper extremity weakness and facial numbness. He was admitted to the hospital with increased weakness throughout the left side. He lives with his wife in a two story house and the bathroom on the second floor. He was an engineer before retirement. 37 Impairments 1. Poor posture: presents with thoracic flexion and posterior pelvic tilt in sitting, weak core strength 2. General aerobic deconditioning: was in the hospital for over a two weeks 3. Decreased sensory input on left resulting in decreased weightbearing and asymmetrical step length left>right 4. Hip weakness: frontal and sagittal plane **hip extensors** most common in many dx and abductors 38 Considerations Based on Impairments 1. Utilize environment for prolonged stretch into an anterior pelvic tilt and thoracic extension 2. Utilize circuit training to facilitate improved aerobic conditioning with functional activities 3. Utilize motor adaptation techniques to increase right sided stepping sensory input on left 4. High challenge stepping to increase activation of hip abductors and extensors and sensory progress to resisted sit to stand. 39 Mowder Tinney

14 Segment 2 40 Motor Learning Considerations Task Specific Motivating Self Control Cueing External Focus of Attention Adjustment of Feedback Challenge Options 41 Knowledge of Results Make a chart to show improvement. Choose outcome measures based on key impairments. What outcome measures would you choose for this patient? Make sure to make a chart for each of your patients. 42 Mowder Tinney

15 Chart DATE Standing Eyes Closed in sec 9/24 10 seconds then put foot down Sit to Stands in 30 seconds 3 with assist of bilateral upper extremities 9/25 18 seconds 3 but with use of one hand only D/C to SNF 9/27 Gait Speed in m/s.2m/s with RW.2m/s with RW 6MWT In feet 50 feet with SOB NT today due to fatigue Self Control Cueing Why can't you stay standing? What do you need to do? Do you want to use the device while you are walking or not? Do you want to perform this in the parallel bars or outside? How long do you think you can perform this activity? What do you want to include in your circuit today? Intervention Options 45 Mowder Tinney

flexors stretch Recommend Sara Meeks webinar http://www.sarameekspt.

16 Poor Posture This should be the first place we ALL start if someone has alignment issues. Basic activities of lying flat with knees supported to facilitate thoracic extension and hip flexors stretch Recommend Sara Meeks webinar She has a pdf on her website as well: _02.asp Sitting Backwards in Chair 48 Mowder Tinney

49 General Aerobic Deconditioning Circuit Training Possible

items do you want to include in your circuit out of the following

How long do you want to do each activity?

17 49 General Aerobic Deconditioning Circuit Training Possible impairments addressed: cardiovascular Self control cueing: Which items do you want to include in your circuit out of the following four: sit to stand, supine to sit, rowing, bike, resisted walking? How long do you want to do each activity? Adjustments to activity: Resisted walking and sit to stand (add weighted vest) 51 Mowder Tinney

Circuit Chart Activity Time Total reps or distance Sit to stand Resisted walking Rowing Decreased Sensory Input on Left Position allows increased sensory input on left but the activity is a motor

18 Circuit Chart Activity Time Total reps or distance Sit to stand Resisted walking Rowing Decreased Sensory Input on Left Position allows increased sensory input on left but the activity is a motor adaptation technique. Left side impaired with short step on right to decrease time/weightbearing on left. To increase step length on right and increase time on left the impaired leg is put on side of treadmill. Good leg should be cued for BIG steps and have them do it fast. Mowder Tinney

Hip weakness Most common weakness you will see in many of your patients is hip extensors. Common limitations leading to gait deviations decreased functional activities.

Stepping Up w/ Assist When they need more facilitation and assist start with this in stairs, parallel bars, or on single step 56 Sit to Stand Possible impairments addressed: decreased force

19 Hip weakness Most common weakness you will see in many of your patients is hip extensors. Common limitations leading to gait deviations decreased functional activities. All of us should be cueing tightening the gluts during standing activities whether it is walking, sit to stand, and dressing. Stepping Up w/ Assist When they need more facilitation and assist start with this in stairs, parallel bars, or on single step 56 Sit to Stand Possible impairments addressed: decreased force production on impaired side, hip weakness, control of quads/hamstrings Self control cueing: how many repetitions do you think you can do this activity? Adjustments to activity: Use a spinning rolling chair when doing sit to stand have them focus on keeping the chair from rolling Resisted sit to stand 57 Mowder Tinney

impairment Dual task training with challenges cognitive, visual, manual, auditory (singing, words start with K,

20 Challenges Eyes closed, Speed change (Slow/fast), Add transverse plane motion, Incorporate a variety of muscle contractions, Visual distracters, Circuit training, Adjust resistance to appropriately address priority impairment Dual task training with challenges cognitive, visual, manual, auditory (singing, words start with K, reading, dialing a phone, etc). Vestibular stimulation (head turns, VOR), somatosensory reweighting Mowder Tinney

21 GOOD WORK! Mowder Tinney

Home Exercise Program Progression and Components of the LTP Intervention. HEP Activities at Every Session Vital signs monitoring

Home Exercise Program Progression and Components of the LTP Intervention HEP Activities at Every Session Vital signs monitoring Blood pressure, heart rate, Borg Rate of Perceived Exertion (RPE) and oxygen