9/9/2014. Amy Cowgill, MOTR/L, C/NDT

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1 Amy Cowgill, MOTR/L, C/NDT The participant will identify the various widely used contemporary therapy approaches for patients with stroke and their explained rationale. The participant will review the literature and research associated with such contemporary approaches. The participant will determine the best evidence based therapy practice patterns for patients with stroke. Rehabilitation is the process of maximizing learning. Some factors that promote recovery in neurological populations include: Understanding of the initial disease process Identification of impairments created by disease process Effects these impairments have on function Creating client-centered goals Skill of clinician to constantly adapt and progress treatment goals/environments to promote therapeutic carry-over 1

Our brains have the ability to rewire neurons to compensate for damage and adjust their activity in response to new situations or changes in their environment.

2 Our brains have the ability to rewire neurons to compensate for damage and adjust their activity in response to new situations or changes in their environment. We know that the area of the brain that was insulted will remain necrotic, however the area immediately adjacent to the insult (penumbra) remains very active after the shock resolves (typically 1-2 weeks) and begins to compensate for the injured portion of the brain. Neuroplasticity occurs via two options: Cortical re-wiring: creating new synapses Neuronal Un-Masking: tapping into unused neurons Plasticity is constrained by the time constants governing coincident input co-selection and by the time structures and potentially achievable coherence of extrinsic and intrinsic cortical input sources. Whaattttttt?! Earlier intervention + increased time = better outcome Various systems can be rewired (visual, cognitive, motor) Use it or lose it! You CAN teach an old dog new tricks Area of brain affected and genetic predispositions can determine recovery Educate your patients on principles of neuroplasticity 2

Therapeutic activities: Must be goal directed, motivating/fun Accurate behaviors must be repeated Give feedback on performance accuracy Make stimulus strength adequate for detection Stimulation must

3 Therapeutic activities: Must be goal directed, motivating/fun Accurate behaviors must be repeated Give feedback on performance accuracy Make stimulus strength adequate for detection Stimulation must be progressed in difficulty Behaviors should be age appropriate Strengthen responses with multisensory modalities Do training in gravitational positions that facilitate task achievement Behaviors should be performed in different environmental contexts Always reward accurate and improved behaviors Increase in area of representation Improved order of representation Improved organization Increased myelination Increased complexity of dendrites Increased strength of responses Improved neurochemical transmission Increased interconnectedness Spread of healthy neurons to take over damaged areas 3

Functional training is a method of retraining the motor system using repetitive practice of functional tasks in an attempt to re-establish the client's ability to perform activities of daily living.

4 Functional training is a method of retraining the motor system using repetitive practice of functional tasks in an attempt to re-establish the client's ability to perform activities of daily living. Functional training can be implemented only after the clinician has fully identified the client s functional limitations/disabilities. Established by the Bobaths in the 1960s Initially, based on hierarchical levels of reflex integration and promotion of normal postural reflexes In recent years the reflex model has been replaced by control model of the nervous system- Nervous system is viewed as dynamic system capable of initiating, anticipating and controlling movements with sensory feedforward and feedback Basic Principles: Task Analysis Approach Facilitate normal movement patterns to counteract compensatory patterns Use of skilled, physical handling techniques Utilizes concepts of neuro-muscular re-education (NMR) and motor learning principles 3 Week certification course for therapists through the NDTA 4

5 Developed in the 1940s-1950s by Herman Kabat, Margart Knott and Dorothy Voss. Basic Principles: Based on the principle that movement occurs in natural patterns (particular diagonals) Utilizes the concept of radiation Coursework: International PNF Association Residencies in Vallejo Institute of Physical Art Multiple PNF courses At present time, there is no research to support or disprove these modalities as a treatment approach for brain injury and/or stroke. The research does demonstrate the approaches to be more effective than no treatment but not more effective than standard care. Limitations in research studies Based on research by Dr. Edward Taub: Highly researched and highly credible treatment approach Basic Principles: Encompasses a family of treatments that integrate basic concepts of neuroplasticity Force Use of involved extremity to avoid non-use Massed Practice: Dosage = 6 Hours / Day Motor Learning 1 Week Certification Course in UAB 5

In a 2008 study on modified CIMT by Stephen Page et al., the magnitude of changes using modified CIMT were found to be consistent with more intense constraint induced therapy protocols.

6 In a 2008 study on modified CIMT by Stephen Page et al., the magnitude of changes using modified CIMT were found to be consistent with more intense constraint induced therapy protocols. Protocol : 30 minutes of 1 on 1 therapy 3 days per week 5 hours per day in restraint (weekdays) 10 weeks * Outcome measures: Action Research Arm Test (ARAT), Fugl-Meyer (FM), and Motor Activity Log (MAL) *Subjective and Objective Motor Gains Page, S. et al., 2008 Most researched treatment approach for stroke and brain injury Treatment approach has been found to be effective in its ability to: Regain lost motor function (especially of the upper extremity) Regain lost function Added effectiveness when used with handling technique such as NDT 6

Addresses dizziness symptoms/ vertigo Peripheral or central origin Exercises to improve VOR (vestibular ocular reflex) and to address motion sensitivity Common after stroke and affects balance

7 Addresses dizziness symptoms/ vertigo Peripheral or central origin Exercises to improve VOR (vestibular ocular reflex) and to address motion sensitivity Common after stroke and affects balance Increased fall risk for patients with vestibular dysfunction Highly significant research on treatment effects Active modality for PT since s especially with SCI population Basic Principles: Safe Environment Allows for early and repetitive gait training after injury Task Specific / Motor Learning Gait is practiced as a task as opposed to parts Treadmill provides facilitation to Central Pattern Generators and Golgi Tendon Apparatus Limitations: Comfort of harness Unstable Spine Unstable BP One of the most widely researched modalities in Physical Therapy BWSTT has proven effective with Stroke & BI: Improved Independence with Functional Mobility tasks including gait, transfers and sitting balance Improved gait speed / cadence Improved outcomes associated with Berg, TUG, Modified Falls Efficacy, 10M Walk LEAPS study (comparison of 2mo vs. 6mo and HEP) Limitations: Discussion of gait quality/symmetry 7

8 Started to become widely used by exercise physiologists in the 1960s-70s (especially in Russia) Basic Principles: Use of hi-voltage electrical stimulation to facilitate lost movement through direct electrical impulse Typically used in conjunction with other tasks: Isolated exercise to increase isolated muscle strength Functional tasks (such as gait) to increase particular motor control during task Proven to be an effective modality for use of motor re-learning of isolated muscle activtation Proven to be an effective modality for functional task training: Improved gait speeds with patients with hemiplegia Improved quad control during stance with patients with hemiplegia Improved heelstrike when used for tibialis anterior Improved grasp/release function with patients with hemiplegia Traditionally, 5 sources of information can be distinguished in relation to motor (re-)learning: 1) proprioceptive information 2) tactile information 3) vestibular information 4) visual information 5) auditory information. But What about imagination?! 8

Motor imagery can be defined as the covert cognitive process of imagining a movement of your own body(-part) without actually moving that body(-part) Kosslyn et al.

9 Motor imagery can be defined as the covert cognitive process of imagining a movement of your own body(-part) without actually moving that body(-part) Kosslyn et al. Initially developed in sport sciences, motor imagery can facilitate the learning of movements. The first clinical studies are promising and suggest that motor imagery training influences motor recovery in a positive way. Mirror Box Therapy Evidence-based practice (EBP) has been defined as "integrating individual clinical expertise with the best available external clinical evidence from systematic research" (Sackett et al. 1996). In clinical practice EBP includes the five components assess, ask, acquire, appraise and apply and this includes the selection of standardized assessment tools, the interpretation of scores on assessment tools and the selection of therapeutic, rehabilitative, or preventive interventions (Leung 2001, Sackett et al. 1996). Functional Mobility: PASS Postural Assessment Stroke Scale Timed Up & Go /Timed Up & Go with Dual Task Berg Balance Test I/ADL s Barthel Index Lawton IADL Test Action Reach Arm Test Fugl-Meyer Assessment of Motor Recovery after Stroke Gait 10 Meter Walk Test 2 Min & 6 Min Walk Test HiMAT Tinetti Gait and Balance Assessment Tool 9

10 9/9/2014 The future of rehabilitation is heavily reliant on the ability of clinicians to adapt to ever changing health care models. Learn, adapt and provide the best treatment Evidence based practice For the least cost Establishing most efficient and adequate care plans With best outcome Measuring patient s functional gains with standardized tests Paci, M. (2003). Physiotherapy based on the Bobath concept for adults with post-stroke hemiplegia: A review of effectiveness studies. J Rehabil Med, 35, 2-7. Taub E, (1993). Constraint-Induced Therapy Combined with Conventional Neurorehabilitation Techniques in Chronic Stroke Patients with Plegic Hands: A Case Series. Am J Occup Ther. 47(1), Page S, Levine Peter. Forced use after TBI: promoting plasticity and function through practice. Shaw, S, et al. Constraint-induced movement therapy for recovery of upper-limb function following traumatic brain injury. Journal of Rehabilitation Research and Development (JRRD) (formerly the Bulletin of Prosthetics Research, 42(6), Karman, N., et al. Constraint-induced movement therapy for hemiplegic children with acquired brain injuries Journal of Head Trauma Rehabilitation, 18(3), Morris, D. M.; Taub, E. Constraint-induced therapy approach to restoring function after neurological injury. Topics in Stroke Rehabilitation, 8(3), Oostra, Kristine M., et al. Motor imagery ability in patients with traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 93(5), Bovend'Eerdt, Thamar J., et al. An integrated motor imagery program to improve functional task performance in neurorehabilitation: A single-blind randomized controlled trial, Archives of Physical Medicine and Rehabilitation, 91(6), Wilson, Daniel J, et al, Ambulation training with and without partial weightbearing after traumatic brain injury: Results of a randomized, controlled trial, American Journal of Physical Medicine and Rehabilitation, 85(1), Brown, Tracy H, et al; Body weight-supported treadmill training versus conventional gait training for people with chronic traumatic brain injury. Journal of Head Trauma Rehabilitation, 20(5), Sietsema JM, et al (2003), The use of a game to promote arm reach in persons with traumatic brain injury, Brain Inj., 17(8), Wittwer JE, Webster KE, Hill K.(2012), Rhythmic auditory cueing to improve walking in patients with neurological conditions other than Parkinson's disease - what is the evidence? Arch Phys Med Rehabil. 4, Clark RA, Williams G, Fini N, Moore L, Bryant AL (2012), Coordination of dynamic balance during gait training in people with acquired brain injury. American Congress of Rehabilitation Medicine. Published by Elsevier Inc. Mumford, Nick; Duckworth, Jonathan; Thomas, Patrick R.; Shum, David; Williams, Gavin; Wilson, Peter H.Upper-limb virtual rehabilitation for traumatic brain injury: A preliminary within-group evaluation of the elements system. Brain Injury, 26(2), Bland, Daniel C.; Zampieri, Cris; Damiano, Diane L., Effectiveness of physical therapy for improving gait and balance in individuals with traumatic brain injury: A systematic review. Brain Injury, 25(7-8), Betker, Aimee L.; Desai, Ankur; Nett, Cristabel ; Kapadia, Naaz; Szturm, Tony, Game-based exercises for dynamic short-sitting balance rehabilitation of people with chronic spinal cord and traumatic brain injuries. Physical Therapy, 87(10), Zhu, X. L.; Poon, W. S.; Chan, Chetwyn C. H.; Chan, Susanna S. H.., Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial. Brain Injury, 21(7), Lettinga, A T; Siemonsma, P C; van Veen, M, Entwinement of theory and practice in physiotherapy: A comparative analysis of two approaches to hemiplegia in physiotherapy. Physiotherapy, 85(9), Wang, R-Y. Effect of Proprioceptive Neuromuscular Facilitation on the gait of patients with hemiplegia of long and short duration. Physical Therapy, 74 (12), Ansari, N. N., & Naghdi, S. (2007). The effect of Bobath approach on the excitability of the spinal alpha motor neurones in stroke patients with muscle spasticity. Electromyography and Clinical Neurophysiology, 47, Eich, H-J., Mach, H.,Werner, C., & Hesse, S. (2004). Aerobic treadmill plus Bobath walking training improves walking in subacute stroke: A randomized controlled trial. Clinical Rehabilitation, 18, Hafsteinsdóttir, T.B., Algra, A., Kappelle, J., & Grypdonck, M.H.F. (2005). Neurodevelopmental treatment after stroke: A comparative study. Journal of Neurological and Neurosurgical Psychiatry, 76,

Vibramoov NEUROREHABILITATION OF THE LOCOMOTOR SYSTEM THROUGH FUNCTIONAL PROPRIOCEPTIVE STIMULATION

Vibramoov NEUROREHABILITATION OF THE LOCOMOTOR SYSTEM THROUGH FUNCTIONAL PROPRIOCEPTIVE STIMULATION Principe of action BRAIN ACTIVATION VIBRAMOOV REVOLUTIONIZES FUNCTIONAL MOVEMENT THERAPY One of the main