Lecture 4 Flashcards
Experience-Based Neuroplasticity and Motor Learning
what are some principles of neuroplasticity?
- use it or lose it
- use it and improve
- specificity
- reps
- intensity
- sailence
- time since onset (the most neuroplasticity in 1st year 3-6 months)
- age
- transference
- interference
FULL community ambulaiton is m/s
1.4 m/s
grading of functional tasks for LE and UE
slides 4 and 5 - read
what’s the importance of errors and variability in practice?
task and environemtn variability is more like real life (enhanced errors during locomotor training enhanced walking ability)
what’s something to be aware of with error / variability during practice?
patient must be able to learn/adapt to the error/variability
don’t reach “too much” (learned helplessness, demoralization, result of failing)
want them to be motivated NOT to fail
plasticity coninutes during ____ because it includes downsizing of dendrites/spines of unecessary input and facilitates storage and consolidaiton of earlier day’s learning
sleep
depression on neuroplasticity
- reduced hippocampus size
- neuronal loss
- less neurogenesis
- deficits in concentration/memory
stress on neuroplasticity
- mild stress enhances learning/memory
- chronic/high stress leads to neuronal loss in the hipocampus
- deficits in concentration/memory
regular ex in mid to late life decreases risk of?
dementia
aerobic ex improves
cognition
neurogenesis
increase dendrtic spine density
angiogenesis
long term potentiaiton
98% of patients with a stroke independently walked at 6 months IF:
- independent sitting balance first 3 days
- LE strength of at least 1/5 in hip flexors, knee extensors, and ankle DF in first 3 days
27% of patients post stroke walked if criteria ?
10% walked if criteria?
- unmet at 3 days
- unmet at 9 days
note: a longer time of no movement is less chance of walking recovery
upon admission to inpatient rehab:
BBS and FIM-L scores
predicts 20x more likely to achieve household ambulaiton by dc
BBS - <20
FIM-L 1 or 2
What is UE functional recovery predictor post stroke?
AROM of shldr and middle finger predicted 71% variance in UE Function at **3 months **
a very early rehabilitation trial (AVERT) results
sig diff in:
- time in PT
- time to first mobilizaiton
- cost of care at 3 months
- function:
- modified rankin at 3,12 months and ability to walk unassisted at 3,6 months
what happened to individuals who participated in the Standing Feedback Trainer (SFT) versus normal treatment?
their center of pressure (lateral) was more towards midline in SFT group.
note: SFT did not necessarily improve their gait but it significantly improved standing balance
unlimited household ambulaiton is
0.27 m/s
limited community ambulation is?
0.58 m/s
unlimted community ambulation is
0.80 m/s
how many m/s needed to cross a commercial street?
2 m/s
community ambulation for adults without stroke is at least ?
1.2 m/sec
“Normal 64 y/o able to ambulate with a speed of 1.07 m/s while chronic stroke survivors of similar age walked at __m/s”
0.8 m/s
supported treadmill ambulation - benefits
- enhance walking for patients that find it hard bc of gravity, posture instability, balance
- enhances motor learning by giving reps
- PT can challenge the patient more
what is the ESSENTIAL neuroanatomy of walking?
- mm and periph nerves
- SC Pattern generator
- VL AND MV SC pathways
- medullary reticular formation
- mesencephalic locomotor region
- subthalamic “ “
what are intrinsic circuits located in the ventral and intermediate gray matter that produces and repeats a functional behavior
for walking, it switches between flexor and extensors
Spinal cord CPG - essential neuroanatomy
what are the general properties of central pattern generators (CPG)?
- involved in intra/interl limb mvmt
- can react appropriately to sensory input
- ability to recover, learn
the decision to walk is made in which center?
medial medullary reticular formation
this area is the final integrative center for locomotion before the cord
“Driving center” for locomotin in animals
decision to walk made here
source of pathway that decends in V-L cord to provide tonic drive to CPG in SC
involved in inter-limb coordination via feedback loops that detect symmetry or asymmetry of limb movement
medial medullary reticular formaiton
why PTs can influence gait at the level of the medial medullary reticular formation?
supported treatmill forces limbs to move symmetrically and that feedback will go to the medial medullary RF. the RF will now be more trained for CPG’s.
note: gait speed is important bc it will control level of feedback going to cerebellum via stretch mm receptors
the mesencephalic locomotor region may help
modulate speed of walking
- “exploraotry locomotion”
subthalamic locomotor region is responsible for
spontaneous goal-directed locomotin
important (but not ESSENTIAL) neuroanatomy
- sensation
- Dorsal lateral pathways
- pontomedullary locomotor strip
- cerebellum
- red nucleus
- lateral vestibular nuclei
- substantia nigra
- GP, Internal segment
- nucleus accumbens
- limbic cortex
the important but not essential regins interact with the essential regions to control locomotion indirectly by?
- timing of swing vs stance phase of gait
- detecting sensory gains during walking
- coordinaiton
- motivation to walk*
____is the top of the dierarchy, where you can identify the motivation to walk. it also explains why “fear” shuts down the system
(test q)
hippocampus
what are the accessory regions?
motor cerebral cortex
pyramidal tract
what might the cerebral cortex participate in?
it may influence initiation, timing, transitioning from stance to swing, and the precise positionnig of the foot
Note: cortex might interfere with walking if attention is required for a task
what are 3 KEY sensory inputs operate the CPG?
- stretch of hip flexors (longer stride**)
- unwieghitng fo tricpes surae (gives leg premission to take step)
- WB to facilitate extensor tone in stance limb (muscle receptors in triceps surae, pressure receptor in foot and joint receptors)
what happens during mid stance to heel-off?
hip extension triggers swing of the limb via activation of the velocity and amplitude dependent muscle spindles
PT should stretch ilioposoas to let the hip swing
keu spinal cord segments on hip flexors
L 2,3,4
If the hip is kept from extending, walking
STOPS
controling and avoiding with gait training
control:
- afferent input associated with the hip flexor stretch and triceps surae
avoid:
- working on static posture if walking is the goal
lokomat paramets can progress patient by:
- increasing speed
- increasing time
- decrease BWS
- decrease guidance forces
note: can adust R/L sides, cadence, hipr aknd knee angles of ROM
lokomat VS manually asisted: key differences
speed: manually assisted can achieve higher speed > lokomat
intervention: need 2-4 ppl for manual assist rather than lokomat (1 person)
level of assist: manually assisted is more specific than lokomat
things to keep in mind on treadmill
- little footwear as possible
- fast as possible on TM
- symmetrical limbs
- hips achieve hip extension in late stance
- arms swinging is ideal
case study: person with chronic CVA
- added AFO by the 4th session increased the total min / session
what is CIMT?
constraint induced movement therapy - forcing to use the the affected limb
develpment of learned non-use
look at table in slide 43
T/F with learned non-use, use-dependent or treatment-induced cortical reorganization can occur with appropriate and aggressive treatment. the brian can reorganize and relearn to use the affected limb, reversing non-use
True
cortical mapping done by TMS or fMRI has shown ____ in the muscle output area size in the affected hemisphere
increases
what are the requirements for cortical reorganization to occur?
massed practice (hours / day and successive days)
high motivation drive and concentration
increased arm use of the affected limb comes form
- overcoming non-use
- use depending cortical reorganizaiton
Candidates for CIMT?
- raise arm to atleast 45 deg
- extend elbow 20 deg when shldr flexed 90 degrees
**ability to extend wrist 10-20 degrees, slightly extend at least 2 fingers - ability to understand and follow directions **
there’s more, read on slide 47
what are components of CIMT protocol?
- repetitive, task-orientent training
- adherence-enhancing behavioral strategies
- contrainging use less affected
repetitve, task oriented practice
shaping (starts with gross shoulder mvmt and finger tips then gradually reaching the goal)
task practice
adherence-enhaincing behavrioal strategies
- sign a behavioral contract
- home diary
- home skill assignemn
- daily adminstration of motor activity log
- home practice
contraining use of LESS involved side using
mitt
note: document wearing time and always reminding the pt to use more involved side
what were significant changes in the UE study (unilateral treat vs bilateral) and nonsignificatnt?
significant:
- fugl meyer
- grooved pegboard
- TMS activation sites significant changes 3 months later
not sig: motor activity log
EXCITE Trial significant changes
- wolf funciton
- motor activity log
- SIS
- Improvements maintained for 12-24 months
Lang C presnetaiton at IV step conference results showed
SLIDE 60
- more is NOT better
- no consistent dose response relationship
- 90% reported sig change
- none changed UE usage at home
- small but sig performance measures for all but the 200 rep group
balance training follwing acute-onset CNS injury
slides 60-64
- strong evidence NOT perform sitting/balance aiming for improved postural stability or WB symmetry for people post stroke
- NOT perform sitting/standing balance training with vibration for ppl post stroke
- dynamic/static nonwalking balance ex paired with virutal reality is strongly encouraged
T/F evidence is stroke to use BWS TM training following acute onset CNS injury (stroke, iSCI, TBI)
false
robotic assisted wlaking training following acute on set CNS injury
not use for ppl post stroke or iSCI
CPG of AFOs and FES post stroke
- very strong evidence AFO and FES improves gt speed, mobility and dynamic balance
- QOL, endurance, mm activation
note: AFO may cause more compensaiton than FES but one isn’t superior from the other - NOT used to diminish PF spasticiy
