Rehabilitation Flashcards
What are the 3 main mechanisms of neural plasticity?
- Unmasking of existing but previously inactive connection
- Axonal sprouting with development of new synaptic connections
- Redundant pathways subserving the same function (i.e. alternative pathway takes over when another has been damaged)
What evidence regarding cortical injuries has been determined from studies on monkeys?
- Peripheral & cortical injuries result in reorganisation of cortical representations
- Differential skin use results in cortical map remodelling
- Monkeys left to recover spontaneously had a further loss of cortical territory in the non-injured area
- Pre-injury level achieved within 4 weeks of repetitive practice
What is the evidence for the use of exercises and mental practice in developing neural plasticity?
- Compared practicing 5 finger exercises on piano to only mental practice
- Resulted in the same increase in cortical area
- Physical performance regarding speed & accuracy better in the manual group
What is the evidence regarding the effects of immobilisation on cortical representation?
Immobilisation of ankle for 4-16 weeks resulted in loss of cortical representation of ankle muscles
What is the evidence for manipulation training?
1 45min session of manipulation training caused a significant increase in the hand area of the motor cortex & motor performance
What is the evidence regarding forced hand use & passive training?
- Compared 1 week of passive training with 1 week UL forced use training
- Forced use resulted in significant enlargement in hand motor area in cortex, increased grip strength & 9 hole peg test
- Passive training had no effect on motor cortex or 9 hole peg test
How many repetitions are required to make a significant cortical change according to evidence?
Approx 15,000 reps
What are the clinical implications of the research regarding neural plasticity?
- Post-injury experience is key to modulating changes in undamaged tissue
- Motor performance & cortical changes can occur with 1 intensive physio session
- Specific task practice, repetition, mental practice & forced use are important factors for promoting cortical change
What evidence is there regarding the physical activity of stroke survivors in rehab & the community?
Patients in rehab are mostly inactive, alone & in bedrooms
Stroke survivors in the community:
- Do low levels of PA
- Are sedentary for 63-90% of the time
- Take few steps per day
- Only walk at light intensity
What did the AVERT trial by Bernhardt et al 2015 find?
- Acute stroke survivors
- Compared early/frequent mobilisation with usual care
- No difference for adverse events or walking
- Shorter/more frequent sessions improved outcomes
What are the clinical implications of the AVERT trial?
- Probably need to leave stroke patients alone for first 24 hours to rest
- After that, need to get them out of bed as often as possible, even if it is only for 5 minutes (short & frequent sessions)
What is the evidence for exercise dose for acute stroke survivors?
- Exercise dose in first week after stroke predicted discharge walking ability
- > 703 reps in first week = faster independent walking
Why is PA so important for stroke survivors?
- Maintains activity performance
- Minimises risk of secondary stroke
- Improvements in activities are possible > 10 years after stroke (never too late)
What does the evidence show regarding time vs amount of practice?
Scrivener et al 2011
- 30 mins = range of 4-369 reps
Lang et al 2009
- 36 mins = range of 1-802 reps
Time is not the same as amount of practice
What are some of the strategies for increasing opportunities for practice?
- Classes
- Forced use
- Video modelling
- Covert monitoring
- Re-organising the therapy area
- Practice books
- Protocol
What are the benefits of rehab classes?
- Allow greater practice opportunities
- Significantly increase mobility & upper limb outcomes
- Efficient use of therapist time
What are the considerations for rehab classes?
- Work stations set up for common problems
- Clear instructions & feedback
- Provision for recording practice (e.g. clicker)
- Exercise progressions
- Use physio aids, volunteers, family, students to assist
- Use group dynamics, group people with similar disability level
- Use different activities
What is the evidence for stroke rehab?
- Daily group sessions of patients with similar levels of disability
- Increased PT by 42 mins/day
- Increased self-directed exercises
- Decreased time spent alone
What is the evidence for task related circuit training?
- Compared with placebo in stroke patients
- Significant improvement in walking speed/endurance, maintained at 2 months follow up
What is forced use?
- Any activity that forces the patient to perform repetitive task practice
- Includes constraint induced therapy (unaffected hand restrained) & treadmill training
What does video modelling involve?
Modelling demonstrations from therapist, another patient or the patient themselves (usually most effective)
What is the evidence for video modelling?
- Videoed patients doing exercises then sent them home, compared to placebo
- Significant improvement in standing balance
- Efficient use of resources
What is covert monitoring?
- Patient’s performance is monitored by unknown members of the rehab team (feel like they’re being watched, do it more often)
- Patient must be able to perform the task criterion
- Results graphed to improve motivation
- Aim is to counteract deterioration of performance outside therapy
What is the evidence for covert monitoring?
- Monitoring of stroke patients whose walking had deteriorated outside therapy
- Assess gait length & width
- Patients improved step length & width daily, reaching consistently normal parameters after 12 ays
What does reorganisation of the unity & therapy area involve?
- Patient & family orientation to the unit
- ADLs scheduled to be part of rehab
- Patients to help each other
- Patients to attend therapy area for most of the day
- Should ensure specific practice areas (e.g. walking, balance)
What should practice books include?
- Diagrams & instructions of key elements, common errors, number of reps/sets & sessions
- Space for recording practice
- Method for discontinuing exercises when no longer appropriate
What are the benefits of protocols?
- Allow interventions to be standardised based on best evidence
- Can improve efficiency of therapists’ time
- Allows use of family & volunteers to assist
What is the evidence for progressive sitting training protocols?
- Patients given a progressive sitting training protocol to follow
- Patients achieved up to 400 reaches in 45 mins
- Efficient resource strategy for practicing over a longer time period
