Week 1 Flashcards
What does the neuromuscular system impact/affect?
- MOVEMENT of all types
- Mobility
- UE function / ADL
- Speech
- Swallowing
- GI/GU
- Sexual function
What can disorders of the neuromuscular system impact?
- Consciousness
- Sensory/perceptual system
- Speech/language
- Cognition/memory/executive function
- Psychological function
- Autonomic function
- Cardiovascular function
How are improvements in function of a neuromuscular problem accomplished?
By increased motor unit firing rates
What is the focus of neuromuscular dysfunction treatment?
Correcting the diminished and interfering patterns of CNS malfunction rather than toward striated musculature
What are the effects of a neuromuscular dysfunction(stroke) on torque production?
- Decrease in maximum voluntary torque
- Decreased speed in torque generation
- Selective muscle weakness at shortened range
What should be the considerations taken when rehabilitating a patients with a neuromuscular dysfunction(stroke) in regard to torque production?
- Target strengthening of muscles in shortened lengths to promote recovery
- Speed/Power has to be trained
What is muscle tone?
Tension in muscle, determined by mechanical factors and motor unit activity
What is muscle tone range?
- Flaccidity
- Hypotonia
- Normal
- Hypertonia
- Rigidity
What is hypertonia?
Abnormally increased resistance to externally imposed movement about a joint
What causes hypertonia?
May be caused by spasticity, dystonia, rigidity, combination of features
What is spasticity?
Velocity-dependent resistance of muscle to stretch
Spasticity is hypertonia in which 1 or both of what signs are present?
1) resistance to externally imposed movement increases with increasing
speed of stretch and varies with the direction of joint movement, and/or
2) resistance to externally imposed movement rises rapidly above a threshold
speed or joint angle
What is the direct causation between spasticity and function?
No direct causation between spasticity and function
Hypertonia associated with a contracture is more related with an abnormal movement may be more about _____
Hypertonia associated with a contracture is more related with an abnormal movement may be more about stiffness of passive tissues
What is that excess muscle activity?
- Compensatory behavior
* Over recruitment when demand exceeds capacity
What are the things to do when trying to determine if a patient has spasticity?
- Improve our movement analysis to discern causes of abnormal movement
- Manipulate the person, environment, and/or task to get a more normal movement
What are the ways to manipulate the person, environment, and/or task to get a more normal movement?
- Fix biomechanical constraints or compensate for them
- Manipulate task and/or environment difficulty to better match demand to capacity
- Increase patient’s capacity(strengthening, practice)
- Decrease degrees of freedom
What are the basic aims of neuro rehabilitation?
- MAKE MOVEMENT BETTER
- IMPROVE FUNCTION
- INCREASE/RESTORE PARTICIPATION
What are the classifications of therapy for neuro rehab?
- Functional Training
- Body system or impairment training
- Augmented feedback training
- Learning-based sensorimotor retraining
What is functional training?
Practice of functional skill; task oriented
What does body system or impairment training focus on?
Focus on correcting body system problem. Do a lot of strengthening, and such
What is augmented feedback training needed for?
Need for external feedback and control over motor program running target task. Can do this by limiting the answer options available for a question
What is learning-based sensorimotor retraining used for?
Improving sensory discrimination dysfunction.
What are the treatment strategy categories for neuro rehab?
- Compensation Training
- Substitution Training
- Habituation Training
- Neural Adaptation
How does compensation training treatment strategy work?
Compensate for permanent impairment or lost body system function
How does substitution training treatment strategy work?
Use of different sensory system or muscle(s) to substitute for lost function of another system
How does habituation training treatment strategy work?
Activity-based provocation of symptoms with goal of symptom reduction
How does neural training treatment strategy work?
Driving changes in structure and function of CNS or PNS with repetitive, attended practice
What word is neural adaptation akin to?
Recovery
What is neural adaptation?
Permanent changes in neural activation, organization, and structure
What are the other definitions of neural adaptation?
- Recovery of neurophysiological activity in affected cortical areas
- Restoration/remodeling toward NORMAL state of organization
What are the goals of recovery?
- Restoring function in neural tissue that was lost
- Restoring ability to perform movements in same manner as premorbid
- Successful task accomplishment using typical “parts”
What are the goals of compensation?
- Neural tissue acquires function it didn’t have premorbid
- Performing old movements in a new way
- Successful task completion using alternative “parts”
What is compensation?
A behavioral substitution; alternative
behavioral strategies adopted to complete the task; use of remaining parts
What does compensation lead to?
Learned non-use
What kind of conditions does compensation create?
Conditions in which CNS does not engage in processing critical information for recovery of motor control. May itself be the primary reason that motor deficits remain.
What are the mechanisms by which functional improvement can occur in a person with a neural dysfunction?
- Recovery
- Compensation
On what levels can recovery and compensation be observed?
At behavioral and neural levels
What does movement emerge from?
- Organism
- Task
- Environment
What is the strategy of neural restoration?
Re- engaging residual brain areas initially dysfunctional after injury or disease
What is the functional platform of neural restoration?
Internal and external redundancy
What is the neural mechanism of neural restoration?
Recovery
What is the strategy of neural recruitment?
Engaging new residual brain areas
What is the functional platform of neural recruitment?
External redundancy
What is the neural mechanism of neural recruitment?
Compensation
What is the strategy of neural retraining?
Training residual brain areas to perform new functions
What is the functional platform of neural retraining?
Internal and external redundancy
What is the neural mechanism of neural retraining?
Compensation
What are the different theories of how recovery takes place?
- Reversal of diaschisis
- Compensation
- Physiological and neuroanatomical reorganization
What is the reversal of diaschisis theory of recovery?
Spontaneous recovery
What is the compensation theory of recovery?
Functional improvement while significant impairment remains
What is the physiological and neuroanatomical reorganization theory of recovery?
- Changes in response to intrinsic neuronal networks
- Alterations/increase in neurotransmitter levels
- Dendritic branching, axonal sprouting, synaptogenesis
- Neurogenesis
How long does it take for a person with a spinal nerve injury to experience reversal of diaschisis if it happens?
24-48 hours
What is plasticity, according to Kleim JA?
The possession of a structure weak enough to yield to an influence, but strong enough not to yield all at once
According to Kleim JA, what is special about organic matter, especially nervous tissue?
It seems endowed with a very extraordinary degree of plasticity
What are the scientific definition of neuroplasticity?
- Fundamental property of the brain
- Capacity for neurons to structurally and functionally adapt
- Reorganization of neural circuits
- Innate capability of the brain to grow new neurons, reorganize cortical representations, access latent circuits, bypass damaged circuits
What is the definition of neuroplasticity for the therapist?
- “Opportunity to train new brain to perform old functions”
- Neural strategies for motor improvement
- True recovery of function
- Maximizing motor recovery
What does the mechanisms of neuroplasticity involve?
Peri-infarct tissue as well as network of sensorimotor structures indirectly affected by injury
What are the structural components of the mechanisms of neuroplasticity?
• Dendritic arbor, spine density • Synapse number • Axonal arbor • Receptor density - Effects population of neurons by changing structure, thickness, gray matter density
What are the functional components of the mechanisms of neuroplasticity?
• Excitatory postsynaptic potential
• Neural activity
• Intrinsic excitability
- Effects population of neurons by changing sensory and/or motor maps, measured by variety of neuro diagnostics
What are the categories of the mechanisms of neural plasticity?
- Synaptic Plasticity
- Non-Synaptic Plasticity
- Neurogenesis
What is synaptic plasticity?
Increases in synaptic strength
What contributes to non-synaptic plasticity?
Changing number of ion channels, increasing or decreasing responsiveness to synaptic inputs
What is are the characteristics of neural reorganization in the absence of rehab?
- Compensatory behaviors key in “normal” response to brain injury
- Reliance on less-affected limb associated with reorganization and neuronal growth in non-affected hemisphere
- Can be maladaptive and interfere with relearning in affected limbs
What is the goal of motor rehab?
To facilitate the neural reorganization that underlies relearning of motor skills and function following damage to the CNS
What is motor relearning?
- Reacquisition of motor patterns
- Adaptation of remaining motor elements
- Integration of alternative motor elements
What is motor recovery?
Reappearance of elemental motor patterns
What is motor compensation?
Appearance of new motor patterns resulting from adaptation or substitution
Skill learning leads to a rewiring of the ____
Skill learning leads to a rewiring of the motor cortex
What is the best hope for brain remodeling?
Learning
_____ causes reorganization
Learning
Brain injury changes how the brain responds to ____
Brain injury changes how the brain responds to learning
Impaired learning after multiple concussions and ____ are related
Impaired learning after multiple concussions and decreased synaptic plasticity related
Functional improvement is a ____ process
Functional improvement is a relearning process
____ not motor activity, leads to increased
numbers of synapses in motor cortex
Motor learning
What the 1st therapeutic for a neuro dysfunction patient?
Be an attempt to recover those specific behaviors disrupted by the brain injury
When should interventions for a neuro dysfunction patient be done and why?
Interventions should be as early as possible to minimize the possibility that the individual will shift from the damaged neural system and attempt to compensate
What are the key factors that make therapy effective?
- INTENSIVE THERAPY
- TASK SPECIFICITY
What are the key factors that drive activity dependent plasticity?
- Task Complexity
- Task Difficulty/Intensity
- Task Specificity
- Sensory Experience
What are the principles of experience- dependent plasticity?
- Use it or lose it
- Use it or improve it
- Specificity
- Repetition matters
- Intensity matters
- Time matters
- Salience matters
- Age matters
- Transference
- Interference
What is the description of principle of experience- dependent plasticity: Use it or lose it?
Failure to drive specific functions can lead to functional degradation
What is the description of principle of experience- dependent plasticity: Use it or improve it?
Training that drives a specific brain functions can lead to an enhancement of that function
What is the description of principle of experience- dependent plasticity: specificity?
The nature of the training experience dictates the nature of the plasticity
What is the description of principle of experience- dependent plasticity: repetition matters?
Induction of plasticity requires sufficient repetition
What is the description of principle of experience- dependent plasticity: intensity matters?
Induction of plasticity requires sufficient training intensity
What is the description of principle of experience- dependent plasticity: time matters?
Different forms of plasticity occur at different times during training
What is the description of principle of experience- dependent plasticity: salience matters?
The training experience must be sufficiently salient to induce plasticity
What is the description of principle of experience- dependent plasticity: age matters?
Training- induced plasticity occurs more readily in younger brains
What is the description of principle of experience- dependent plasticity: transference?
Plasticity in response to one training experience can enhance the acquisition of similar behaviors
What is the description of principle of experience- dependent plasticity: interference?
Plasticity in response to one experience can interfere with the acquisition of other behaviors
What are the components of intensity?
- Repetition
- Time in therapy
- Frequency of therapy
- Cardiovascular response
- RPE
- Functional
- Challenging
- Load
- Speed
What are the active ingredients required to drive neuroplasticity?
- Practice should be challenging
- Practice should be progressive and optimally adapted
- Solicit motivation and active participation
What are the components of the challenge that can drive neuroplasticity?
- Difficult but not too difficult (require new learning)
- Specific
- Intense
What are the components of the progressive and optimally adapted practice that can drive neuroplasticity?
- “Repetition without repetition”
* Timing matters
What are the components of the motivation and active participation that can drive neuroplasticity?
- Active and engaged
- Motivation enhances motor learning
- Salient and meaningful
What is motor learning?
Acquisition and/or modification of movement
What is the process of motor learning associated with?
Practice or experience leading to permanent changes in skill
What are the concepts of motor learning?
- Process of acquiring capability for skill
- Results from experience or practice
- Can’t be directly measured; inferred from behavior
- Produces relatively permanent changes in behavior
What are the other components associated with motor learning?
- Learning new strategies for sensing as well as moving
- Emerges from perception, cognition, action processes
- Search for task solution, emerging from interaction of individual with task and environment
What are the key factors in motor learning?
- Practice
- Feedback
- Attention
- Motivation
What are the “familiar” factors in motor learning?
- Practice Levels
- Feedback
- Practice Conditions
What is the most important factor in retraining motor skills?
The amount of practice
What are the types of feedback used in motor learning?
• Intrinsic
• Extrinsic
- Knowledge of Results (versus Knowledge of Performance)
What are the practice conditions of motor learning?
• Massed v Distributed • Constant v Variable • Random v Blocked - Contextual Interference • Whole v Part • Transfer • Mental Practice • Guidance v Discovery Learning
What are massed practice conditions?
Amount of practice time in trial ˃ amount of rest between trials
What are distributed practice conditions?
Amount of rest between trials ≥ amount of time for trial
What is the effect of massed practice in continuous tasks?
Massed practice decreases performance
(fatigue), not much affect on learning
What is the effect of variable practice?
Increases ability to adapt and generalize
When is the Constant v Variable practice condition most useful?
When learning tasks performed in variable conditions
What are the benefits of random practice conditions?
Better retention and transfer
What are the benefits of blocked practice conditions?
Better performance
What is the contextual interference of random v blocked practice conditions?
Increased difficulty initially make learning more effective
When may random practice be inappropriate?
Until earner understands dynamics of task
What are the characteristics of whole v part practice conditions?
- Interim steps via task analysis
- Practice parts before combining into whole
- Takes things out of context
- Quick, discrete skills and continuous skills should be practiced as whole
- Serial skills are ok to do part-whole
- Bottom line, have to get to the WHOLE practice sooner rather than later
What is a transfer practice condition?
A task learned in one condition transferred to another
What do transfer practice conditions depend on?
Similarities between tasks or environments
What are the characteristics of mental practice, practice conditions?
- A cognitive rehearsal
- Enhance learning when physical practice not possible
- Has been shown to significantly increase efficacy of repetitive task specific practice
- Retention of motor improvements have been demonstrated to last at least 3 months in patients with stroke
What are the characteristics of guidance v discovery learning practice conditions?
- We often use guidance in neuro rehab
- Unguided conditions less effective during acquisition, but more effective for retention and transfer
- Replace with discovery learning – patient allowed to explore “perceptual motor workspace”
- Trial and error discovery of best strategies and perceptual cues
What type of feedback is the best?
Intrinsic
What type of extrinsic feedback is better for learning?
Knowledge of results
What does attention learning have to do with?
External focus
What does motivation learning have to do with?
- Enhanced expectancies
- Autonomy
What are the types of focus of attention that we can have during motor learning?
External or internal
What is external focus of attention?
Concentration on movement effect
What is internal focus of attention?
Concentration on body movements
What does feedback promoting external focus do?
– Enhances learning
– Promote automaticity
Does frequent with external focus negatively impact learning/retention?
No it doesn’t
What does autonomy increase?
Motivation, performance, and learning
What mediates autonomy?
Self efficacy
What does expectancy focus on?
Positive feedback
What kind of effect does expectancies have on self efficacy?
Positive effect
What does enhanced expectancies do?
- Warn and prepare for further positive outcomes, impact cognitive, emotional and motor preparatory activity
- Influence goal setting and increase positive affect
- Buffer against responses that would detract from optimal performance
- Couple goals with desired outcomes
What does autonomy support do?
- Facilitate learning indirectly by enhancing expectancies
- Role of autonomy for triggering switches between neural networks needed for given task success (efficient goalaction coupling)
- Perception that actions have effects on environment important for motivation
- Heighten sense of personal agency and personal expectations for positive outcomes
What are the values that skilled decision making incorporates?
- Functional goals from beginning
- Intentional prevention for optimal health
- Patient-centered/family-centered decisions
- Holistic approach
- Evidence based
- Emphasis on carryover to home activities
How should interventions be driven/centered?
Patient centered not diagnostically driven
What are the 3 parts of interventions?
- Coordination, communication, documentation
- Patient/client related instruction/education
- Procedural intervention
What is the flow of the hypothesis- oriented algorithm for clinicians II (HOAC II)?
- Collect initial data –>
- Generate patient- identified problems (PIPs) list —>
- Formulate examination strategy (consultation if needed) —>
- Conduct the examination, analyze data, refine hypothesis, and carry out additional examination procedures needed to confirm or deny hypothesis —>
- Add non- patient- identified problems (NPIPs) to the problem list —->
- (for each existing problem: generate a hypothesis as to why the problem exists) (for each anticipated problem: identify the rationale for believing anticipated problems are likely to occur unless intervention is provided) —->
- Go to refine problem list —->
- For each problem: establish one or more goals
- For each existing problem: establish a testing criteria. For each anticipated problem: establish predictive criteria (consultation if needed) —>
- Establish a plan to reassess testing and predictive criteria. Establish a plan to assess the status of problems and goals (consultation if needed) —>
- Plan intervention strategy based on hypothesis and anticipated problems (consultation if needed) —>
- Plan tactics (consultation if needed) —>
- Implement tactics
What is the sequence of the temporal stages of movement?
- Initial conditions
- Preparation
- Initiation
- Execution
- Termination
- Was outcome achieved?
What are the components of the initial conditions in the temporal stages of movement?
- Posture
- Ability to interact with the environment
- Environmental context
What are the components of the preparation in the temporal stages of movement?
- Stimulus identification
- Response selection
- Response programming
What are the components of the initiation in the temporal stages of movement?
- Timing
- Direction
- Smoothness
What are the components of the execution in the temporal stages of movement?
- Amplitude
- Direction
- Smoothness
What are the components of the termination in the temporal stages of movement?
- Timing
- Stability
- Accuracy
What type of feedback negatively impacts learning?
Internal feedback
What is autonomy?
When a patient is allowed to have some decision making power in what is going on in their plan of care
