Neuroplastic Principles Flashcards
Components of neurorehab
- compensation
- recovery/restoration
Components of neurorehab: compensation
- optimizing new skills while learning new methods to minimize loss of motor function
- use an AFO, adapt environment (ramps, higher toilet seats, grab bars)
- adaptive equipment (walkers, wheelchairs)
Components of neurorehab: recovery/restoration
- restoring loss of motor function/skill
- restoring strength, gait speed, ability to perform
- neuroplasticity
Neurorehab principles
- specificity
- repetition
- intensity
- time
- salience
What does neurorehab presume?
exposure to specific training experiences leads to improvement of impairment by activating neural plasticity mechanisms
Neuroplasticity is dependent upon?
genetic (developmental process)
Experience expectant neuroplasticity
brain is producing brain connections by innate processes and normal development
- vision is a subtype (visual system is developing in a timely fashion based upon the normal expectant sensory input
Which type of neuroplasticity occurs after a neurologic injury?
experience induced
- a vast array of input (motor learning, skilled motor activity, skill adaptation)
What does experience neuroplasticity depend on?
- diet
- type of exercise
- environment
- stress
- natural aging
- neurotrophic factors
- brain reserves
Why is task oriented practice important?
promotes localized brain changes that may be beneficial at the acute stage after stroke
In patients with an acute brain injury the sensorimotor cortex activity is abnormal, what is linked to more recovery?
normalization of motor activity patterns is linked to more recovery (task oriented)
- early rehab start regardless of intensity
- short bursts
ex: sit in chair for 20-30 mins then go to bed, getting up stabilized the motor system to allow for better recovery
Long term potentiation (LTP)
the key to permanent change
Neuroplasticity is?
a constant process in both positive and negative ways
What does long term potentiation involve?
persistent strengthening of synaptic connections occurring from high frequency presynaptic activity
- involves persistent strengthening of synaptic connections occurring fro high frequency presynaptic activity
Changes occur at cellular level:
there are more neurotransmitters in the synaptic clef when you practice and learn which will bring in more receptors
- presynaptic neurotransmitters
- number of postsynaptic receptors
Aerobic exercise and resistive exercise in neurogenesis:
increases cerebral blood flow and hippocampal neurogenesis to enhance memory
Known contributors to neural remodeling:
- increased circulating neurotrophins
- synaptic strengthening
- modified gene expression
- dendritic remodeling
- myeline plasticity
- cytogenesis
Other applications to motor system plasticity:
- motor learning (learning new motor skills enhances neuroplasticity)
- spine density (learning new kills increases dendritic spine density)
How is the basal ganglia affected with motor learning?
when you learn a new skill it creates new dendrites (dentritic spines) in the basal ganglia which enhances brain growth and the neurons survive longer because they’re being used
Examples of skills that can promote neurogenesis
ping pong, swiss ball bowling, sticks
- any that work anticipatory postural control
New skills in people with CVAs
learning (or relearning) a skill with new motor-sensory deficits is similar to learning a new skills
- task based activity will reduce the change of non use
- transfers like sit to stand and bed mobility
- good body mechanics and ground reaction forces
Task based training dosage: stroke
- wait 24 hours to ensure patient is medically stable
- smaller doses more frequently throughout the day
- exercise done in larger amounts starts at 2-3 months after stroke
GREATER THAN 3 HOURS OF REHAB SHOWS BETTER OUTCOMES THAN LESS THAN 3 HOURS
What does strength training do for SCI patients?
increases spinal motor neuron excitability
- strength training in rats showed a greater number of excitatory synapses onto the AHC but no increases in inhibitory synapses
What does co-activation activities do for patients?
leads to changes in spinal cord with reduction in Ia transmission (muscle spindle)
- Ia fibers send inhibitory signals to antagonist muscles which reduces co-activation
Multimodal stimulation
more than one sensory or motor activity targets brain activity
- improves memory and attention
- improves cognition and processing
- good for stroke and PD
- not as good for MS (MS has lesions everywhere and the others are in a specific area)
Multisensory integration shows?
enhancement in speed, detection, localization, and reaction to biologically significant events
- well documents in superior colliculus (SC)
What does the superior colliculus do?
synthesizes concordant combinations of visual, auditory, and somatosensory signals to enhance vigor of the reponses
Visual stimuli has?
salience
- it drives attention and instills motivation
attention = frontal lobe
motivation = basal ganglia
vision = occipital lobe
What involves multimodal stimulation?
incorporating auditory and visual information during a motor task
- allows for varying tempo, task difficulty, and cognitive load
- improves anticipatory control, and dual tasking
** you are combining tasks, if they can do two separate tasks try having them do it together
Multimodal stimulation outcomes in PD:
- improves turning in gait
- reduces festination
- improves speed
Gait intensity for CVA
moderate to high (60-85% HRmax)
Brain activity and movement
- goal orientated = premotor cortex
- aerobic exercises = frontal lobe executive function
- skilled performance = cerebellum (while performing)
- learning new motor skills = parahippocampal gyrus, dendritic growth, brain reorganization
Variable activity and neuroplasticity
- increase leg strength via stair climbing
- increase balance via perturbations during walking
- walking in multiple directions (lateral, backwards, diagonals)
- walk over obstacles
- leg weights
Neuroplasticity tenet…
intensity matters!!!
How long should you use TENS for?
better at 30 mins
What does TENS work?
works on the muscle spindles (resets the spindle)
TENS for pain modulation
(TENS) is considered an adjunct or standalone treatment option
- works at spinal cord and brain
- electrical impulses
**pain is NOT musculoskeletal it is neurochemical
Stepped care model for pain: 1st step
- life style
- pain education
- medications
- non-invasive neuromodulation
- physical therapy
Stepped care model for pain: 2nd step
- changes to 1st step plan
- stronger meds or weaker meds
- pyschosocial elements
- non-invasive neuromodulation
Stepped care model for pain: 3rd step
- advanced therapy
- pain adjuvants
- invasive neuromodulation
- surgery
- strong opioids
Where does TENS fall for the stepped care model for pain?
under non-invasive neuromodulation
- nerves like warmth (makes the patient feel comfortable)
Why do we use non-invasive neuromodulation?
GATE CONTROL THEORY
–> flood the AHC with other stimuli so the patient stops feeling the initial pain (hot, vibration, tactile, cold)
Negative neuroplasticity in neuropathic pain: gate control theory
flood the synapses with other stimuli so that there isn’t “space” for pain
- other receptors become stronger to those stimuli because they are being used
- when the receptors aren’t being used they will decreased and get less strong eventually decreasing the pain sensation
Experience dependent neuroplasticity in PD
also called explicit neuroplasticity
- requires goals and tasks
- incorporate goal based training and aerobic activity
- motivation
- cognition
- visualization of exercise
- improvements in cognition and automatic components of motor control seen
Neuroplasticity in MS
- task oriented training changes volume of white and gray matter
- 2-6 weeks of training changes white matter
- high intensity exercise with visual feedback, resistance exercise, balance training, running training
What does resistance training do for MS patients?
refines corticospinal tract connectivity, enhances established synapses, and increases AHC activation
- may also reduce tau protein
Motor priming
preparing the nervous system to perform
Example of motor priming
cardiovascular activity (task A) will induce plasticity within neural circuits that are directly relevant for the performance of another activity (task B)
Nu-step —> prime —> walking performance (step length)
Why is aerobic activity important for neuroplasticity?
lactate and BDNF are produced which alters the cortical excitability, reducing GABA inhibition in M1
Typical dosage for neurorehab:
- 20-60 mins/day
- at least 16 hours extra within the first 3 months (~70+ mins/day)
- high dose rehab protocols with extended training hours induce structural plastic changes and reorganization of neural networks
Effective neurorehab programs should?
incorporate principles of both specific brain areas within the motor cortex and brain region networks to counteract neuronal degradation and promote improvement
- specific brain areas (massed practice, dosage, variable practice, multisensory stimulation)
- brain region networks (mirror therapy, goal oriented practice, cueing, knowledge of results, increasing difficulty)
Dosage
training of more than 5 hours/wk
- speeds up functional recovery
Structured practice
training schedule with frequent and longer breaks
- better retention than massed protocols
Task-specific practice
movements performed are relevant for ADL and goal oriented
- learning is maximal if the task trained is specific
Variable practice
several tasks that require different movements
- better retention and enhances generalization
Multisensory stimulation
provides feedback through multiple senses
- restoration of sensorimotor contingencies
Increasing difficulty
progressively increase the difficulty of the task or the involved movements
- augment task specific use of the impaired limb
Explicit feedback
knowledge about results, task success or failure, movement outcome
- retain and adapted movement better
Implicit feedback
knowledge about performance that is obtained from tracking, analyzing, and visualizing kinetic movement data
- reduce the sensorimotor prediction error and promote learning
KEY POINTS
- mod-high intensity (65-85% HRmax) improve walking speed and distance
- VR training with gait is effective but hard to find in hospitals
- strength training, cycling, and circuit training are inconsistent in improving walking distance and speed but should still be considered
- static and dynamic balance activities designed to improve postural stability and WB don’t contribute to locomotor function improvements
- body weight supported training/robotic training does not improve locomotor function in chronic patients unless at a high intensity and HR
Create adaptations for each intervention
- change the surface
- provide narrow pathway or complex navigation
- change speed, stops, and turns
- add cognitive load
Clinicians create opportunities for neuroplastic growth:
- implicit and explicit feedback
- patient first principles (watch patient’s affect for boredom, attention, motivation)
- be prepared and quickly transition when needed
