Neurological Therapy Flashcards
Define Neuroplasticity
The adaptive capacity of the CNS and its ability to modify its own structural organization and functioning
Neuroplasticity refers to an array of mechanisms that contribute to neuronal reorganization and is thought to be the primary mechanism by which recovery from CNS damage occurs.
Mechanisms of neuroplasticity
Unmasking of dormant pathways - changes in synaptic strength
a. Many neural pathways lie dormant naturally – these dormant pathways become more effective once the primary pathways that were previously being used are removed or incapacitated following disease or injury
b. These pathways increase in synaptic strength with continued use
c. (Synapses not normally used, following an injury (stroke) are then called upon and strengthened with continual use)
Collateral sprouting - formation of new synapses
a. This occurs in conjunction with neural re-organisation and as a response to demand from intact cells to denervated region
b. Prior to collateral sprouting - Damage to axon/nerve cell occurs, causes nerve degeneration - means unable to deliver AP disrupting nerve signals from being delivered to tissue
c. Formation of new synapses via collateral sprouting from intact nerve cells to where damage has occurred causing denervation (stops pain transmission)
What affects motor learning
- Age
- Co-morbidities
- Medications
- Genetics
- Exercise and pre-conditioning
- Prognosis/ diagnosis
Factors influencing motor learning
- Practice
- Feedback
- Attention/active participation
- Confidence/self-efficacy
- Motivation
- Sleep
How to influence practice for motor learning
More practice results in improvement in skill:
Part vs whole practice:
- In continuous motor tasks, the current portion of a movement is dependent on the movement just completed and, therefore, these tasks are best practiced in their entirety
- In sequences of movements that will be coupled, part practice can be beneficial if used properly since a learner can perform pieces of the movement and have some degree of success providing increased motivation to learn the skill, and then combined for whole practice
Distribution of practice:
Performed at once (massed) VS should rest breaks be sprinkled throughout (distributed)
- Massed practice requires all the trials to be performed in a manner that minimizes the amount of rest between trials so there is more time on task than there is spent during rest.
- Distributed practice divides repetitions into smaller chunks to allow for rest between trials
- Dependent on the goal of the practice session and the individual’s capabilities (strength, endurance, cognition, ability to focus on task)
Variability of practice:
Variable practice involves performing variations of the task or completely different tasks throughout a treatment session
- Blocked schedule = would require that all practice be completed under one condition before moving on to the next
- Random schedule maximizes variability; practiced in random order
- Serial schedule requires a sequence to be followed until all 30 trials
Contextual interference - the effect of different practice schedules on learning
- Blocked practice = low interference in memory as a person practices multiple trials repeatedly
- Random practice = high interference because trials are interrupted by other tasks
- Higher contextual interference (random practice) may lead to poor performance it frequently leads to better learning (as measured with retention and transfer tests) compared to blocked practice. May occur because in random practice the skill must be reconstructed on each attempt, allowing an individual to practice a variety of strategies
In very complex tasks or in individuals with significant neurological impairments blocked practice may best because of the increased chance for success during practice providing motivation to continue with practice
Opportunity to explore movement - making it interesting
Learning from errors (exclude dementia) - each attempt provides the information about both what to do, and what not to do in order to achieve the goal
Developing OWN perception of movement - important for transfer of skill
Mental practice:
Involves cognitive rehearsal and imagining of a motor action with the goal of improving performance but without the production of overt physical movement
Successful in helping improve skill because, when performed, the neural processes involved in imagining the movement are very similar to those required for physical performance and low level muscle activity (submovement activity) occurs
Specificity and Location of Practice:
Task-specific/task-oriented practice is an approach to rehabilitation that focuses on performance of functional tasks that are meaningful to the individual
Types of Feedback
Feedback refers to information an individual receives pertaining to the performance of a task:
Inherent feedback:
Information about the movement gained through interpretation of sensory, visual and auditory experiences
Own perceived:
- Knowledge of results
- Knowledge of performance
Augmented feedback
External information is primarily used to enhance task-intrinsic (inherent) feedback
May have a more important role and serve as a replacement if impairment is present in a sensory system
Verbal, visual (demonstration), or physical (manual guidance)
How to influence augmented feedback for motor learning
Verbal augmented feedback:
Is provided as either knowledge of results or knowledge of performance
Knowledge of results:
- Information related to the outcome and in most cases is redundant information because by the time a task is completed the performer is usually aware if they were successful
- May be useful at any time during the learning process but is particularly useful in the earlier stages because it can serve as a motivator
Knowledge of performance:
- Pertains to information regarding execution of the task and typically relates to the type or quality of the movement
- Best used in the later stages after the goal of the movement is realized and now the information provided about varying aspects of the movement can be more readily understood by the performer
Composition of augmented feedback:
Active learning is thought to be crucial because it emphasizes the process of continuing to solve new and different motor problems as they arise, rather than just being provided with the solution
Early stage of learning would do better with prescriptive or active-engaging feedback that is more general and qualitative in nature with an external focus on what was done correctly:
- Whether the information given should be general (about the movement itself) or specific (about a particular portion of a movement)
- Qualitative (that was faster than last time) or quantitative (that was 3 seconds faster than last time)
- Comprised of information related to an internal focus of attention (lift your arm to shoulder height and extend your elbow) or external focus of attention (reach to turn on the light switch)
- Whether information should be provided regarding the correctness of the movement or on the errors
Frequency of augmented feedback:
Can be provided concurrently during a task or it can be provided after a task is performed (terminal)
Concurrent feedback may actually hinder retention and transfer because the performer or the individual performing the task, becomes reliant on that feedback to complete the task successfully
Less feedback is best = augmented feedback can enhance learning but it has also been found that too much can hinder learning as patients naturally become dependent on feedback
Amount of feedback should be reduced as therapy progresses; achieved by:
- Using an intermittent schedule of when feedback is given that consists of summary or average information regarding a selection of previous attempts
- Using a faded schedule that initially provides a lot and then is reduced as practice continues
- Setting up boundaries (bandwidth) where feedback will be given only if an error is too large or too small
- Allowing the performer to have some control and decision-making over when and what type of assistance is provided during task practice
Manual guidance:
Is when a therapist passively moves a patient-learner in an effort to provide more appropriate proprioceptive feedback
- Important when safety is a concern but when learning or relearning a skill it is suggested that manual guidance = concurrent feedback thus patient becomes dependent on that feedback
- May lead to learning (as measured through retention and transfer) being slowed since during practice the learner did not need to actively solve the motor problems
How to influence attention/active participation for motor learning
Focalization, concentration, of consciousness, is at its essence. It implies withdrawal from some things in order to deal effectively with others; involves/stimulates brainstem
Conscious vs unconscious or automatic:
Learning should be conscious and progressed into unconscious>automatic
Limited capacity (dementia, attentional deficit):
Dual tasking and diverting attentions should be prevented
Use of external focus:
- Consistently been found to have a beneficial effect on motor performance and learning
- Use of analogies may serve the same purpose by directing attention externally to the production of a given image, rather than to body movements
Strategies to improve attention:
- Break tasks into smaller component tasks.
- Provide breaks during and between tasks.
- Provide explicit step by step instructions.
- Use simple language and instructions that are concise.
- Allow longer timeframes in which to complete tasks.
- ‘Chunk’ tasks into smaller, manageable components.
How to influence motivation for motor learning
Promoting motivation:
- Enthusiasm
- Connect with patients
- Empathy and understanding
- Encourage and reward (links with feedback)
- Get involved – personal goal-setting, meaningful
- Be creative (links with practice)
- Explanations - more likely to it if they understand the reasons behind it
- Talk about their strengths – boost confidence
- Reduce anxiety
How to influence self-confidence (self-efficacy) for motor learning
Self-confidence is the belief that one can successfully execute a specific activity
Links with intrinsic motivation and feedback
Related to self-esteem, locus of control and personality:
Internal/external locus of control - if they feel responsible for their improvement VS if they feel somebody else is responsible
Extrovert vs introvert personality - extrovert more likely to feel confident and make the changes
Enhanced Expectancies:
past performance accomplishments establish a foundation for a sense of confidence or self-efficacy and previously positive outcomes give rise to positive expectations for future outcomes in similar circumstances.
Stages of memory formation
- Encoding - memory representation formed
- Consolidation - memory becomes more permanent
- Stabilisation - Maintenance of motor skill performance offline; not dependent on sleep
- Enhancement - improvement in performance of a skill offline; sleep dependent
- Storage - maintenance of memory over time
- Recall - memory brought out of storage for use
Relationship between sleep and memory
Sleep generally is classified into 2 different stages: non–rapid eye movement sleep (non-REM) and rapid eye movement (REM)
Normally enter non-REM sleep first and then REM
Alternate cyclically 4 – 6 cycles a night
REM is important for:
Memory of people and events (declarative memory) occurs in the medial temporal lobe and hippocampus
Memory of movement (procedural memory) occurs in sensorimotor cortex, cerebellum and basal ganglia
Sleep is needed for the enhancement stage of memory production (declarative/procedural)
Therefore sleep is essential for the consolidation of motor memory
What are the different stages of motor learning?
Cognitive (thinking):
Decision framework is set up - we work out the basic movement pattern needed to achieve the goal
- Subjects may verbalise each part of the task
- Words appear to help recall
Associative:
- Component parts of skill tried out
- Elementary units of action assembled
- Associations made between components of skill - make connections between skill and motor processes
- New patterns of action emerge
Autonomous:
Focus switches from “what to do” to “how to do” the movement better
- Degree of cognitive control is minimised - becomes automatic
- Loss of ability to give verbal description of task
- Verbalisation may interfere with performance
- Reduced attention demand
- Predictability important to automatisation
