Treating Patients With Neurological Deficits Flashcards
O que é a neuroplasticidade?
There is evidence to support that differential experience can change the structure and function of various brain regions.
Tissue adjacent to damaged area can take over, residual neural tissue can compensate.
The brain changes both anatomically and physiologically with resultant changes in growths of new connections, membrane excitability, or unmasking of preexisting connections.
Adult brains need to attend to stimuli and be actively part of the activity for change to occur. Specific reinforcement schedules and feedback are beneficial.
Existem desvantagens associadas à neuroplasticidade?
It is certain that adaptive plasticity takes place in an acute brain lesion and that rehabilitation can influence it - this can be “good” or “not so good” depending on the training. Por exemplo, um utente pode conseguir-se levantar-se da cama após uma lesão cerebral aguda, porém a forma como o faz pode não ser a mais correta a longo prazo - e essa formação neural incorreta é difícil de substituir (não impossível, mas mais desafiante).
Quais são os aspetos-chave para promover a neuroplasticidade?
- Task-oriented training (relevant and interesting to the patient);
- Repetition (repetition, repetition) with meaning and motivation;
- Challenging: using a problem based learning situation that uses the environment to promote active participation of the patient (planning, executing and adapting within the activity).
Qual a importância do desafio em tarefas específicas?
Want to assist the brain in convincing the brain that: the current state is not good enough; the brain can reorganize to tolerate higher demands than real life.
Challenge is critical component of pushing the brain with a threat of failure to maintain attention on task.
Qual o papel do clínico através das tarefas específicas?
Not just a good performance... Learning is goal-oriented. So the goals of the therapist: – Choose the appropriate task; – Structure the environment; – Vary the task; – Progressively increase the complexity; – Try new tasks.
Quais são os requisitos de aquisição de uma competência ou habilidade?
– Consistency;
– Flexibility - ability to modify movement;
– Efficiency - reduce unnecessary movement.
O que implica o princípio da repetição? E o que se pretende promover através da repetição?
- Practice, practice, practice;
- Try to provide repetition within a changing environment that promotes problem solving;
- The practice needs to make sense and mean something.
Promoting Neuroplastic Change. There is a relationship between dose vs. response improvements.
O que é o controlo motor?
The ability to regulate or direct the mechanisms to movement.
Há várias teorias que o tentam explicar, mas todas apresentam as suas limitações.
O que nos diz a Dynamic Systems Theory?
Movement results from the dynamic interplay between multiple systems that are organized around a behavioral goal and constrained by the environment.
O que é a aprendizagem motora?
Motor Learning: study of the acquisition of motor skills. A more permanent change in a movement that occurs via longer-term practice.
Recovery of function refers to re-acquisition of movement skills lost though injury.
Em que domínios existem interações para que ocorra Motor Skill Performance?
Skill, Environment and Person.
Quais são as etapas da aprendizagem motora?
Cognitive, associative and autonomous.
Quais as considerações acerca da fase cognitiva da aprendizagem motora?
Learn the nature of the task, lots of conscious effort;
Direct attention to the movements, rely on sensory cues.
Quais as considerações acerca da fase associativa da aprendizagem motora?
Skill is honed, Reduce amount of cognitive activity;
Distinguishes between error and correct performance.
Quais as considerações acerca da fase autónoma da aprendizagem motora?
Low degree of attention required to complete a task;
Moving toward skill.
Quais são as três grandes aplicações da aprendizagem motora?
- Feedback (Fading; Intrinsic Versus Extrinsic; Knowledge of results and knowledge of performance; Positive Reinforcement - building competence, selfconfidence, and autonomy).
- Transfer of Learning (Allowing error);
- Practice Schedules (Blocked vs random, Constant vs variable, etc).
Porquê desvanecer o feedback?
Physical guidance is better in the beginning but not for long-term carry over.
Need to fade the feedback as the patient is able to recognize their own errors.
Quais os tipos de feedback?
• Intrinsic feedback – Feedback that comes to individual through sensory systems; Visual and somatosensory; Works independent of working memory.
• Extrinsic Feedback – Giving verbal feedback to your patient; Can be given concurrently with the task or at the end; Has been shown to be detrimental to some
learning.
Porque devemos utilizar feedback de foco externo? Dá um exemplo.
Use cues that use an external focus. External focus cues were linked to greater movement ease, automaticity, or fluidity.
For example – if you want increased knee flexion, do not cue to bend knee more (increases cognitive cueing) but change environment and cue them to step over object.
O que enfatizar no feedback que providenciamos?
Important to emphasize successful performance and ignoring less successful attempts, benefit learning. Also linked to increased motivation.
Other research has shown that instructions presented as learnable, enhanced learning.
Que estratégias podemos utilizar para promover autonomia e competência?
- Positive feedback strengthens self confidence – “How confident were you performing this activity?”; “Did you get it the way you wanted?”.
- Build up sense of choice – “How many times do you want to practice this?”; “What do you think we could do here?”
Qual a relação entre a tentativa e o erro, no que concerne à aprendizagem?
- Allowing a patient to trial and error will facilitate the nervous system for improvement;
- Trial and error practice is one critical aspect to motor learning – Adjust guarding and allow errors within safety guidelines (por exemplo, queremos que eles percam o equilíbrio para que o seu cérebro aprenda sobre aquele erro); Adjust challenge to increase opportunity to error.
Porém, definitely not optimal for patients with cerebellar damage (porque a natureza da lesão dificulta a integração da componente do erro).
O que é a adaptação motora?
Adaptation is defined as the process of adjusting a movement to new demands through trial-and-error practice.
– Significant errors seen in the beginning because CNS does not correctly predict the new situation; Once the CNS has adjusted and then challenge is withdrawn error will occur in opposite direction; Short-term learning process; Cerebellum input is necessary for successful adaptation.
How do you get a patient to correct abnormal movement patterns that the nervous system may not perceive as erroneous or requiring correction?
Need to perturb the system (theraband, weights on
ankle, split belt treadmill, size of objects).
The more practice you can give a patient, the more the patient learns. Quais os tipos de condições para praticar?
– Massed versus Distributed; – Constant versus Variable; – Random versus Blocked; – Whole versus Part; – Guidance versus Discovery.
Qual a diferença entre Massed versus Distributed practice?
Massed: practice superior to rest.
Distributed: rest equal or superior to practice.
Constraint Induced Movement Therapy is a common example of massed practice.
Qual a diferença entre Constant versus Variable practice?
Which condition results in increased generalized learning?
Constant: practicing at the same speed.
Variable: practicing at variable speeds.
Variable.
Qual a diferença entre Random versus Blocked practice?
Qual o principal benefício de cada uma das condições?
Random: practice multiple skills in one session.
Blocked: practice one task in one session.
Blocked is better for cognitive impairments and random is better for increased generalized learning.
Qual a diferença entre Whole versus Part practice?
Whole Training: practice task as a whole.
Part Training: practice task in interim steps.
Se estamos numa fase aguda, o paciente vai fazer tarefas parciais, progredido para tarefas em whole training para aumentar o desafio.
Qual a diferença entre Guidance versus Discovery practice?
Guidance Learning: physically guided through task (Ex: NDT).
Discovery Learning: no guidance given during practice.
Quais são as opções e considerações gerais para a aprendizagem motora?
- Task/Environment
- Error
- Self-efficacy/Feedback considerations
- Intensity
- Practice conditions
- Challenge/Progression.
A patient is learning the skill of supine to sit for the first time following a right CVA with left sided weakness. He is currently 3 days post CVA and is in the acute care setting. What stage of learning is the patient currently in?
Cognitive Stage.
Since this is the first time they are performing the activity this patient is in the cognitive stage. The cognitive stage is defined as first learning the nature of a task and requiring conscious effort and relying on sensory cues.
A patient is learning supine to sit for the first time, so the therapist decides to give feedback that is directly related to the movement pattern. Qual é o tipo de feedback?
Knowledge of Performance (KP).
KP is feedback relating to the nature of the movement or movement pattern used to achieve the goal which is what the question is asking.
What is Knowledge of Results feedback?
Knouledge of Results (KR) is terminal feedback that is about the outcome of the movement.
Since the patient is first learning the task then the patient would benefit from receiving feedback on how to achieve the movement which is Knowledge of Performance (KP).
A 59 year-old with a left CVA is attending outpatient physical therapy to work on increasing his gait speed. What the therapist can decide?
Provide daily reinforcement of walking speed.
The findings by Bruce et al. found that walking speed did increase with daily reinforcement while not increasing with no reinforcement of the walking speed.
A therapist identifies the need for her patient to be able to generalize her functional activities to all environments as a priority focus of treatment. Therefore which is the best practice condition for the sessions?
Variable practice (practicing at variable speeds) and random practice (practicing multiple skills in on session) is the best combination of these choices to help generalize functional activities.
Que princípios de tratamento poderão ajudar em caso de pusher syndrome?
- Change environment to give visual cues – Use visual aids and specific verbal cues to give feedback about body orientation.
- Perform treatments in an upright position – must work on vertical.
- Do not PASSIVELY correct.
- Use verbal and visual cues for patient to actively correct themselves.
Dá um exemplo da progressão de objetivos que poderemos negociar com um utente com pusher syndrome?
- Patient able to maintain sitting without falling with moderate visual and verbal cues in 2 days.
- Patient able to maintain midline for two minutes while brushing hair with visual cues in 5 days.
- Patient able to perform sit pivot even surface transfer with no extension of intact upper extremity with verbal cues only in 2 weeks.
A patient is admitted to an acute inpatient rehabilitation facility and described to the therapist as having pusher syndrome. Quais os três achados clínicos que encontramos neste tipo de condição?
Leaning toward paretic side, abduction and extension of nonparetic extremities, and resistance to passive correction.
After concluding the patient has a pusher syndrome presentation, the therapist reviews the literature. Although there is no full agreement, which is the area of the brain hypothesized damaged?
Right or Left posteriolateral thalamus.
The therapist decides to get the patient up for the first time and wants to set up the environment to provide the most successful attempt. Which can be choosed?
Place a bedside table along the intact side but a little forward, place a water bottle on the table and cue the patient to reach forward for the bottle. Progress to standing.
