L21: Implementing Intensive Dose in Neurological Rehabilitation

Question 1

What are the 10 principles neurological rehabilitation?

Answer 1

1. Use It or Lose It – Failure to drive specific brain functions can lead to functional degradation.
2. Use It and Improve It – Training that drives a specific brain function can lead to an enhancement of that function.
3. Specificity – The nature of the training experience dictates the nature of the plasticity.
4. Repetition Matters – Induction of plasticity requires sufficient repetition.
5. Intensity Matters – Induction of plasticity requires sufficient training intensity.
6. Time Matters – Different forms of plasticity occur at different times during training.
7. Salience Matters – The training experience must be sufficiently salient to induce plasticity (meaningful, important…)
8. Age Matters – Training-induced plasticity occurs more readily in younger brains.
9. 9. Transference – Plasticity in response to one training experience can enhance the acquisition of similar behaviors.
10. Interference – Plasticity in response to one experience can interfere with the acquisition of other behaviors

Question 2

What are 3 things we know about repetition practice in neuro rehab?

Answer 2

1. Task specific practice that is delivered in high dose has been established as an integral ingredient in neurological rehabilitation
2. Functional improvement may be accelerated when the dose of task-specific practice is increased
3. Animal studies have demonstrated changes in neurological structure AND improved functional performance with >400 repetitions of a functionally meaningful task
   
   • 400-600 repetitions per session of upper limb tasks induce changes to cortical representation and motor skill acquisition
   • 1000-2000 steps performed per session to improve stepping
   • Different to MSK where the aim is to build strength
   • Skill acquisition takes longer learn

Question 3

Evidence suggests that _____ of repetitions daily of upper extremity practice and _____ of daily repetitions of lower limb practice are required to produce neural change and optimize rehabilitation of function

Answer 3

hundreds; thousands

Question 4

Current best practice guidelines suggest inpatients in rehabilitation should receive _____ daily of physiotherapy, occupational therapy and speech therapy

Answer 4

one-hour

Question 5

Mean active time in physiotherapy sessions was ____ minutes. On average ____ % of therapy was inactive time. Therapy involving walking practice comprised only_____ minutes per session. What is the implication of this?

Answer 5

32.8; 40%; 8.7

In an hour physio session –> only active for half the time and unactive for the rest

Question 6

What is the reality of physio in neuro rehab? What does this mean?

Answer 6

• Dose currently provided during rehabilitation (most known about stroke and TBI) is substantially smaller than what is suggested to be required for neuroplastic change
• A large percentage of physiotherapy sessions are spent inactive
• If you get 37 minutes of physiotherapy and are inactive 40% of this time… only 22.2 minutes
• If goal is to achieve 1000 reps of a task… patient needs to be working at 45 reps/minute without resting…. NOT POSSIBLE…
• •The idea of therapy being ONLY what occurs in the rehabilitation space with the therapist needs to be DISMISSED
• Therapy is ALL opportunity for activity throughout the entire day… (and night… 24 hours!)
• Prescribed therapy needs to be optimized (less inactivity)

Question 7

What are 5 other benefits of intensive rehabilitation except for skill acquition?

Answer 7

1. Cardiovascular fitness
2. Increased strength, endurance
3. Self esteem/sense of achievement
4. Earlier discharges?
5. Less dependence on discharge?

Question 8

What are 8 barriers to implementing intensive doses in therapy?

Answer 8

1. Time allocated to therapy – traditional models of 1:1 therapy
   
   • Eg. groups (eg. sitting –> upper limb, balance and mobility)
2. Safety
   
   • Eg. 30 patients in gym with 6-8 staff –> how have deficits and can have accidents/falls
3. Skill of individual therapist
4. Lack of space/equipment
5. Patient expectations
   
   • They think that they are “done” (eg. older and have had a stroke)
6. Difficulty motivating/pushing patients
   
   • When to push patient and when to back off –> social interaction skill
7. Staff attitudes (physio and other health disciplines)
8. •Reduced quality of intervention performance

Question 9

Problem: Time allocated to therapy

What is the answer and 4 characteristics?

Answer 9

Shift the notion of what therapy looks like and offer patients more opportunity

1. Consider implementing circuit/group classes
2. Increase the opportunity for independent/supervised practice
3. Be aware of and look to reduce inactive time
4. Consider all interactions or any participation in an activity as part of therapy and maximize the opportunity for patients to participate

Question 10

Problem: Safety/Skill of therapist

What are the 4 answer?

Answer 10

1. Consider set up of exercises
2. Assess patients suitability for completing independent/supervised exercises
3. Consider therapy assistants or family to assist (where appropriate)
4. Experience… continually evolve to improve your ability to provide intensive rehabilitation

Question 11

Problem: Lack of space/equipment

What are the 4 answer?

Answer 11

1. Prioritize equipment to maximize available space
2. Be innovative to problem solve space issues
3. Consider what other areas can be used… eg, ward space, outdoors
4. Simplify equipment needs

Question 12

Problem: Different staff attitudes

What are the 4 answer?

Answer 12

1. Evidence
2. Education
3. Participation
4. Demonstrate positive outcomes

Question 13

Problem: Reduced quality of intervention

What are the 4 answer?

Answer 13

1. Targets/appropriate set up that enable patient to perform desired exercise and self-monitor accuracy
2. Education
3. Use of family/therapy aids
4. Prioritize and compromise

Question 14

Problem: Difficulty motivating and/or pushing patients

What are the 4 answer?

Answer 14

1. Education
2. As a therapist, be a coach not a friend
3. Show patient improvements – however small!
4. Link the hard work to patients goals

Question 15

What are 5 characteristics of coaching/education?

Answer 15

1. Educate the patient clearly on the purpose of an
2. activity…
3. Link the activity to achieving a meaningful goal
4. Collaborate with the patient on what is meaningful to them… never assume…
5. Give accurate feedback on performance so that a patient is learning during their rehabilitation- Give honest feedback but don’t discourage effort
6. Education and learning about rehabilitation is critical for self management of chronic health conditions/disability

Question 16

What are SMART goals?

Answer 16

• Specific
• Measurable
• Attainable
• Relevant
• Timely

Question 17

What are 4 characteristics of motivating through goals?

Answer 17

1. Each treatment session should have a goal… (however small)
2. Ensure the goal is measurable to appropriately track change
3. Ensure the goal is a building block to the bigger picture goals
4. Give the patient feedback on their performance relative to the goal and collaborate to set a new goal for the following session

Question 18

What are 3 characteristics when carefully considering the exercise set up to implementing intensity?

Answer 18

1. Use targets to give patient feedback and increase accuracy of performance
2. Use walls, tables, bars etc… to ensure safety
3. **Understand the difference between what a client can complete independently versus what they require assistance for**

Question 19

What are 3 characteristics when recording the reps and working tpwards a goal when implementing intensity?

Answer 19

1. Up to 21% overestimation when therapy is reported by therapists
2. Patients are actually surprisingly reliable…
3. Use a tally counter to be accurate

Question 20

How do you implement intensity for weak hip flexors (impairments)?

Answer 20

Question 21

How do you implement intensity for hip flexion in rolling (part practice)?

Answer 21

Question 22

How do you implement intensity for weak knee extensors- lower level (impairments)?

Answer 22

Question 23

How do you implement intensity for weak hip extensors- lower level (impairments)?

Answer 23

Question 24

How do you implement intensity for weak hip and knee extensors- higher level (impairments)?

Answer 24

Question 25

How do you implement intensity for hip and knee extension in STS- (whole task)?

Answer 25

Question 26

How do you implement intensity for progressing STS retraining?

Answer 26

Question 27

How do you implement intensity for the upper limb?

Answer 27

Question 28

Neurological rehabilitation should be _____ , goal directed and ____specific

Answer 28

intensive; task

Question 29

To implement intensive dose patients need the opportunity for ______ and/or _____ practice because traditional therapy models are_____

Answer 29

independent; supervised; limited

Question 30

What are 4 principles to consider for therapists developing programs for independent and/or supervised practice?

Answer 30

1. Safe exercise set up (environment, equipment, GM vs AG)
2. Education to motivate patients
3. Specific measurements of performance to monitor change
4. Feedback on performance (example: targets, scales etc…)