maximizing functional recovery across the …...maximizing functional recovery across the continuum...
TRANSCRIPT
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Acute & Chronic Stroke
Mike Studer, PT, MHS, NCS, CEEAA, CWT, CSST
Maximizing Functional Recovery Across the Continuum
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• Financial– None
• Non-financial– None
Disclosures
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• Identify physiologic changes at the level of the brain and in the body that occur in many individuals months and years post CVA (stroke)
• Apply recent evidence in motor learning and motivation to maximize the recovery for clients in acute and chronic stroke rehabilitation
• Apply recent evidence in practice structure and feedback to maximize the recovery for clients after stroke
• Debunk rehabilitation myths about recovery dependence on timing and technology in effective rehabilitative outcomes in those recovering from stroke
Objectives
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Chapter One
The Physiology of Stroke in Rehabilitation
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• Staging or triaging rehabilitation• Timing of rehabilitation interventions for safety and
efficacy
• Designing rehabilitation programs for specific impairments
• Anticipation of associated impairments• Patient and family education
• Advancing our professions
The Relevance of Recovery:Understanding Neuroplasticity
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• Finished• Cannot change
• Done
• Sorry• One year
• We tried • Six months
• Nothing more we can do
Chronic Stroke: Time Frame?
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• After six or more months post stroke– Can we expect to make gains?– Where can we expect to make gains?
Ballester B, Maier M A critical time window for recovery extends beyond one-year post-stroke. J Neurophysiol. 2019
Stroke Rehabilitation: Potential
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• Time frame: acute and long-term • How long is the window for recovery after stroke?
• Studies have shown neurologic change can occur more than five years post stroke
Neuroplasticity
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• Successful novel experiences• New connections
• Improved use of neurotransmitters
• Frequently used, efficient pathways• Improved blood flow
Neuroplasticity: Learning Bases; Structural and Chemical
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How Does the Brain Reorganize?
• Physiologically– Synaptogenesis– Angiogenesis– Dendritic arborization– Synaptic efficacy– Collateral sprouting
• Functionally– Habituation– Adaptation– Compensation
(substitution)
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• Habituation is a reduction in the magnitude of the response to repetitive sensory stimulation, and it is induced by repetitive exposures to a provoking movement
• Habituation is specific to the type, intensity, and direction of the eliciting stimuli– In most cases, the provoking movement is a less
frequently executed movement during daily activities– Repetition of the originally abnormal signal will stimulate
compensation
Habituation
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• Definition: readjusting expectations from a learned “set”– Changing the gain of the VOR or vestibulospinal reflexes– Expectations of an extremity being available to assist– Adjusting after a sensory signal is lost
• Adaptation describes the routine changes in sensitivity (gain) of reflexive eye movements (vestibulo-ocular reflex [VOR]) with head motion or the equation of balance in neuropathy
Adaptation
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• Definition: using alternative strategies or sensory modalities in an effort to function despite the severe impairment in or total loss of another
• Visual compensation after vestibular lesion• Changing procedural patterns of hand dominance
• Weight shifting• Choosing modes of communication (gestures over
speech)
Compensation: Substitution
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“Why”: Stimuli to Induce Neuroplasticity
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• Reinforced learning (success, food, feedback)• Persistent error signals
– Foot drop, loss of balance, missed target
• Danger/fear that is real or imagined• Pain, dizziness, blurred vision (reshaping symptoms)
Why Does the Brain Reorganize?
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Neuroplasticity: Mechanisms and Methods
Mechanisms Methods
Synaptogenesis Repetitions
Dendritic arborization Struggle/challenge/failure
Synaptic efficacy Success
Angiogenesis Salience
Measurable change
Observable change
Vicarious experiences
Overload principles
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Neuroplasticity Principles
1. Use it or lose it: failure to drive a specific brain function can lead to functional degradation
2. Use it and improve it: training that drives a specific brain function can lead to an enhancement of that function
3. Specificity: the nature of the training experience dictates the nature of the plasticity
4. Repetition matters: induction of plasticity requires repetition
5. Intensity matters: induction of plasticity requires sufficient training intensity
Kleim and Jones 2008
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6. Time matters: different forms of plasticity occur at different times during training
7. Salience matters: the training experience must be sufficiently salient to produce plasticity
8. Age matters: training-induced plasticity occurs more readily in younger brains
9. Transference: plasticity in response to one training experience can enhance the acquisition of similar behaviors
10.Interference: plasticity in response to one experience can interfere with the acquisition of others
Kleim and Jones 2008
Neuroplasticity Principles (cont.)
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• Task complexity1
• Task difficulty2
• Task specificity3
• Task intensity4
1. Jones et al., 19982. Plautz, Milliken, and Nudo, 20003. Nudo et al., 19974. Sullivan et al., 2002; Van Pragg et al., 1999
Practice Variables for Neural Plasticity
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• Constraints: forcing or directing behavioral or motor choice to enhance recovery
• Incentives: tangible reward, praise, or accomplishment as a direct function of success
• Avoidances: shaping motor control through fear, pain, embarrassment, or error
Neuroplasticity: Stimuli
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• Hemianopsia: food on left side of plate• Hemiparesis: sit-to-stand with one foot in front, or
constraint-induced movement therapy (CIMT)
• Strength/motor control: weights on ankles• Initiation: timing choice reaction or motor performance
Constraints
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• Motor control: typing or texting (word is correct if we are accurate)
• IADL: self-feeding a favorite food
• Endurance: finishing a race, arriving• Expression: positive feedback after a public speech
Incentives
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• Imbalance: tightrope/tandem walk up on platform• Neglect: getting lost in an obstacle course with choices
to the left
• Pain: low-surface sit-to-stand with arthritis• Dysphagia: coughing on a new/advancing texture
Avoidances
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Chapter Two
Where Can They Improve? Seven Domains of Potential for Your Patient
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• Neuroplasticity: motor• Neuroplasticity: sensory
• Muscular strength
• Muscular endurance• Cardiovascular endurance
• Psychological • Cognitive
Resources in Stroke Rehabilitation
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• As discussed: demand and supply• Task specific
• Repetition based
• Functionally relevant• Engaging (see OPTIMAL)
• Error enhanced• Must be challenged and see progress
Motor Control Neuroplasticity
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• Remove or inhibit sensory strengths • Occluded subject vision
• Inhibited somatosensation: compliant
• Head motion• Aberrant visual stimulation
• Increase the need for/importance of extremity-based input
Somatosensory Reweighting
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Forcing the brain to recognize AND need the UE:
• Opportunistic
• Use
• Therapy
Somatosensory Reweighting UE: OUT
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Where Do Gains Come From?
• Capabilities– Neuroplasticity sensory– Neuroplasticity motor– Neuroplasticity
integration
• Capacities– Strength– Muscular endurance– Cardiovascular
endurance– Psychological (fear-
based losses)– Cognitive (attention,
reaction speed, decision-making)
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• Muscular strength• Muscular endurance
• Cardiovascular endurance
• Psychological• Cognitive
Fitness (Physical and Mental) Training: Capacity
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• Resistance tolerated 8 to 12 reps• Three to four days per week
• Two to three sets
• Expect soreness• Specific to stroke
– Bilateral strengthening is important for motor control– Mirroring, overflow, and forced use – Unilateral: less impaired followed by more impaired
Muscular Strength
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Muscular Strength (cont.)
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• Resistance 15 to 20 repetitions• Three to four days per week
• Multiple sets
• Specific to stroke– Consistent repetitions with focus on
cadence/rpm/symmetry– Observable or measurable output from affected side– Functional relevance in mm endurance soon
Muscular Endurance
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Muscular Endurance (cont.)•
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• Sustained activity, whole body as able• 30 minutes
• Ten minutes, three or more/day acceptable (cumulative)
• Four to seven days per week
• Specific to stroke– Much more active when fear is eliminated– Consider mechanism for stroke in prescription– Involuntary/abnormal tone can be expression of fatigue
Cardiovascular Endurance
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Stroke applications– Functional training: sit-to-stand, level ground gait– Body-weight-supported treadmill training
• Percent of preferred walking speed overground• Percent of maximal walking speed overground• Perceived exertion on treadmill
High-Intensity Interval Training
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• Intensity: deliver earlier• Intensity: deliver greater and with safety
• Psychological: allowing patients to see capacities and freedom in an involved lower extremity
• Dual task: push cognition overlay in mobility for the benefit of both (manual, cognitive, visual, auditory)– Fold newspaper, carry plates, button shirt, brush teeth– Tell me the directions to ____, the sequence of ____– Can you identify what is going on in this photo?– Listen to this story, and hold a conversation after
Body-Weight-Supported Treadmill
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• High-speed or weighted lower extremity efforts, BWSTT• Sit-to-stand repetitions
• Targeted standing balance (instrumented/functional)
• Standing without upper extremity support or vision: compliant surface
• Ascending stairs, leading with affected lower extremities
• Sit-to-supine repetitions• Machine-based HIIT (semirecumbent/BWS)
Task-Specific Circuit Training: PT/OT
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• Sit-to-stand repetitions• Standing without upper extremity support or vision:
compliant surface
• Sit-to-supine repetitions• Speed demand donning coat/sweater/shoes
• Targeted sitting balance (functional reach)• Sorting silverware fast, bilaterally
• Machine-based HIIT (UBE)
Task-Specific Circuit Training: OT
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• Spontaneous word generation• Reading fluency
• Swallowing mixed textures
• Visual comprehension and recall• Naming flashcards
• Singing a familiar song• Auditory comprehension and recall
Task-Specific Circuit Training: SLP
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• How does fitness reduce disability?• How does fitness prevent disability?
• How does fitness influence neuroplasticity (two)?
The Fitness Cycle
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Fitness
Neuroplasticity
Functional integration
Preventing disuse loss
Preventing accidental loss Fitness
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• Muscular strength• Muscular endurance
• Cardiovascular endurance
• Psychological– Self-efficacy– Fear-based inactivity– Low expectations fulfilled– External forces on psyche (perceptions)
• Cognitive
Beyond the Body: Psychological
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• Understand that the brain can change• Understand that I can improve
• SEE that I have improved
• Challenge: opportunity to improve• Use measurements to prove potential
Psychological: Fear and Efficacy
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• Read personalities• Integrate patient preferences
• ICF: roles and responsibilities
• OPTIMAL theory of motor learning– Autonomy– Enhanced expectancies– External focus
Psychological: Personalized and Attentive
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• Stimulate awareness: for accuracy in judgment • Reaction speeds
• Judgment/inhibition
• Dual-task capacities
Cognitive: Reserve, Speed, and Safety
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Chapter Three
Evidence-Based Stroke Rehabilitation: Acute and Chronic Recovery Principles
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• Optimizing• Performance
• Through
• Intrinsic• Motivation
• Attention• Learning
Lewthwaite, Wulf – 2016
OPTIMAL
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• Brief periods with higher demands– Consider nearly any task made harder: speed, reaction time,
balance requirements, forces, complexity of environment
• Exceeding self-predictions• Exceeding therapist-stated expectations• Holding task performance in constraint
– Constraint-induced practice to be discussed
• Setting new PR in objective measures• Enduring longer than expected• Struggling and persevering
Enhanced Expectancies: Applications
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• “You have to force your patients to succeed”• …when they expect to succeed, they
– Try harder and pay more/full attention– Try to beat their own expectations– Try to exceed your expectations– Receive dopamine, reinforcing learning
Neurophysiologic Benefits of Enhanced Expectancies
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Image used courtesy of Rebecca Lewthwaite
OPTIMAL Theory of Motor Learning
Motorperformance
SELF-FOCUS
FOCUSONTASKGOAL
ATTENTION
MOTIVA
TION
Autonomy
Externalfocus
Enhancedexpectancies
Goal-ac'oncoupling
Motorlearning
OPTIMALtheoryofmotorlearning
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• Choosing a constraint or aspect of practice for their input
• Choosing the order of practice
• Providing first-order feedback (respected opinion)• Choosing a level of difficulty
– Perceived exertion becomes a measure for dosage
• Setting new PR in objective measures
• Enduring longer than expected
• Struggling and persevering
Autonomous Support: Applications
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Autonomy and Enhanced Expectancies:
In Action!
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• Neurotransmitter and neuromodulators– Dopamine– Serotonin– Endorphins
• Growth factors– BDNF/IGF/GDNF
• Reduces cortisol
Neurophysiologic Benefits of Autonomous Support
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• History of Borg Scale• Applications
– Cardiovascular workload– Strength workload– Cognitive challenge (ADL, speech, IADL)– Balance1
• Future applications– Gait speed, sit-to-stand height– Difficulty of reading, naming, or swallowing (texture)– ADLs in complexity, time, memory, or surface
1. Espy, et al
Perceived Exertion Drives Dosage: “Autonomy Meets the Borg Scale”
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Espy, D: Used with personal permission
Perceived Exertion Drives Dosage: “Autonomy Meets the Borg Scale” (cont.)
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• Therapists cue to goals that are inanimate, not body parts
• Educating patients for self-application
• Analogies of sport• Seeing success through visualization of goal
completion• Creating opportunities in the clinic
• Compensatory applications with EF
External Focus: Applications
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• Applications in sport (goalpost vs. foot, rim vs. fingertips, hole vs. wrist)
• Applications in ADLs (self-feeding, dressing)
• Applications in swallow• Effectively interrupting the procedural memory pathway
through the basal ganglia for a more part-task focused program through M1
Neurophysiology and Neurophysiologic Benefits of EF
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Automaticity, Skill, Procedural: Rehab
• Direct focus to– Body parts– Sequencing assistive
device– Act of dynamic balance– Verbal cues from
therapist• Direct focus to
– A secondary task– An end
goal/destination
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• Patient choice without burden• Patient involvement without being patronizing
• Teamwork, not hierarchy
• Facilitating choice within reality and personality
Supporting Autonomy (AS)
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• Principles of motor learning apply (KR/KP)• Consider the stage of learning for each person
• Focusing on– External– Environmental– Movement effects
Focusing Externally (EF)
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• Reinforcing vicarious experiences: PT and patient• Recalling recent gains prior to the next trial
• Affirming language
• Dyad training• Videotape support
Enhanced Expectancies (EE)
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Area of Focus: Gait Speed and Symmetry
• Traditional– “Spend less time on your
right”– “Take steps more
frequently”– “Cane, left, right …”– “Make sure you place
your heel down first”– “Don’t let your L knee
snap back”
• Optimal: enhanced– “Can you get there in fewer
steps?” (EF)– “Do you believe you can
make it in 17 strides?” (EF/AS)
– “That’s impressive! When we started, this took 22 steps. What is a reasonable goal for you now?” (EE/EF/AS)
– “Show me how tall you can walk … scrape your head up against an imaginary ceiling as you walk” (EF)
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Area of Focus: Sit-to-Stand
• Traditional– “Lean forward more”– “Put equal weight on
both legs”– “Don’t lean back as you
stand up”– “Push from your hips
first”– “Don’t straighten your
knees first”
• Optimal: enhanced– “Imagine there is a
band holding you back into the chair” (EF)
– “Are you able to sit down like you are trying to be very quiet?” (EF)
– “Wow! Great job! Do you want to try to get up from a lower surface now?” (AS/EE/EF)
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Area of Focus: Curb Ascent
• Traditional– “You have to go up with
your left leg first”– “Put the cane up on the
step with you before you push up”
– “You need to really lean on the left and lift the right foot up high”
• Optimal: enhanced– “Which leg do you feel
can best lift your body up there today?” (AS)
– “The last time we tried this, you did very well. Can you recall what worked for you?” (AS/EE/EF)
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Area of Focus: Functional Reach and Pour
• Traditional– “Try to turn your wrist
and forearm over”– “Don’t lift your shoulder
blade up so high”– “You should be able to
do this …”
• Optimal: enhanced– “Are you able to focus
on fully emptying the cup?” (EE)
– “Excellent job! Would you like to try to move the cup farther away, or are you ready for more water in the cup?” (AS/EE)
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Area of Focus: ADL/Dressing
• Traditional– “Don’t lift it by hiking up
your shoulder”– “You are losing your
balance as you are thinking about putting on the shirt”
– “Put your left arm in first”
• Optimal: enhanced– “Can you show me a few ways
to lift your arm and tell me what feels best?” (AS)
– “Do you believe you can keep pressure on both legs of the chair while you put the shirt on?” (EF/AS)
– “How many seconds do you believe that you can balance without needing help?” (EE)
– “May I offer some advice?” (AS)
– “Can we try this with a few techniques, after which you can tell me what feels best?” (AS, EF)
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Area of Focus: Dysphagia
• Traditional– “Tuck your chin as you
swallow”
• Optimal: enhanced– “May I offer you some
advice?” (AS)– “How many bites in a row
can you take without coughing?” (EE)
– “Do you believe you can make it through a full meal without coughing?” (AS/EF)
– “On our first meal together, you took two bites before coughing. Today, you managed 25. What is a reasonable goal for you now?” (EE/EF/AS)
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Area of Focus: Speech
• Traditional– “Let’s try this word-
finding task”– “Please read this
paragraph aloud”– “Please name the
animal on each card as fast as you can”
• Optimal: enhanced– “How many cards in a
row can you name correctly?” (EE)
– “Do you believe you can read this full paragraph without pauses?” (AS/EF)
– “Your first score on this word-finding task was 71 seconds. Today, you did this in 55. What is a reasonable goal for you now?” (EE/EF/AS)
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Chapter Four
Motivational and Exercise Attributes After Stroke
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• Depression and mood• Self-efficacy
• Optimism/pessimism and personality
• Apathy• Task specificity and salience
• Balance of success and challenge
Motivation: Critical Variables
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• Autonomy• Mastery
• Productivity
• Dopamine if surprising/stimulating/successful• Serotonin if wellness for self
• Oxytocin if wellness for others
Self-Efficacy
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• Attention• Personalization
• Gamification
Motivational Considerations
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Attention– Test– Measurement– Prediction– Reporter
Motivational Considerations (cont.)
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Personalization– Priming– Salience/specificity/autonomy– Enhanced expectancies
Motivational Considerations
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• What is help, to you?• What areas do you need and think you can improve?
• I can help you. I have helped others.
• I will hold both of us accountable• How hard can you be pushed?
• How will we know that you are improved?
Patient Engagement
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Gamification– Measurements– Patients informed of scores, upcoming tests– “High-score fever”
Motivational Considerations
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• Motivation of measurement• Access to competition
• Sustained attention
• Transfer of training?• Reduction of fear?
• Access to visualization (VR most notable)• Limited risk through avatar
Gamification
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• Attention• Motivation
• Intensity
• Automaticity
The Essential Concepts to Apply
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How Is Your Current Engagement Approach Working? Fear and Threats
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• Personality• Self-efficacy
• Motivation
• History (work, ACEs, etc.)• Interests
• Past rehabilitative experiences
Subjective Examination
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• Individual attributes influence response to challenge, tolerance of intensity, tolerance of error, and reward systems
• Practice without sufficient incorporation of individual personality traits may not provide optimal dosage, and could cause either boredom or agitation
Personality/Tolerance
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• Competitive• Depressive
• Instructive (awareness)
• Shaming• Burdensome
• Motivational• Frustrating
• Shaping
The Individualized Role of Errors
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• SIRROWS stroke study• Yesterday, your walking speed was
• Today, your walking speed is
PROVE Outcome Expectations: What Did You Accomplish?
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• Modified SIRROWS stroke study• Yesterday, your walking speed was
• Today, predict your walking speed
PROVE Outcome Expectations: What Did You Accomplish? (cont.)
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Capture attention through– Interest/salience– Test
– Challenge– Patient predictions– Patient reporting– Autonomy
– Goal-direction– Measurement/gamification– Error estimation
– Dyad training
Maximize Outcome With Intensity
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Predictions (EF)
1. An external focus of attention directs attention to the task goal, enhancing goal–action coupling
2. An internal focus of attention impedes performance by directing attention to the self
3. Movement success resulting from an external focus enhances expectancies for future success
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• Consider patient personality• Confidence
• Self-efficacy
• Patients may be competing against themselves, you, another patient, or an issued “challenge”
Intensity = Challenge = Interest
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• Patients estimate their abilities, become invested in the outcome
• Ask them to predict– “How much help will you need?”– “How much time will it take you?”– “How many times will you lose your balance?”
Intensity: Patient Predictions
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• Reinforcing learning from previous efforts• Advancing patient awareness
• Fewer cues or “logic” from therapists– Pre-task delivery with post-task review– “How will I do next time?”
Intensity: Patient Predictions (cont.)
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Break
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Chapter Five
Practice Structure and Feedback Attributes After Stroke
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• Task specificity• Feedback timing, frequency, and mode from therapist
• Timing of blocked/random practice
• Frequency and degree of failure/error• Introducing constraints and loading
– Physical load– Cognitive load– Endurance– Accuracy/skill
Practice Structure and Feedback
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• Specificity• Frequency
• Redundancy
• Feedback• Evolutions with learning
• Success vs. boredom: challenge point hypothesis• Error-induced training
• Automaticity and dual-task loading
Practice Variables
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• How frequent?• What kind (mode)?
• What indicates feedback is needed?– Goal, bandwidth, frequency, request
• Source?
• Content KR/KP• Direction: intrinsic, extrinsic
• Autonomy, mastery, permission
Feedback
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• Enable patient to improve through intensity• Force the brain choose improvement (reaction speed,
symmetry, efficiency)
• Less from the therapist, more from patient’s brain• The more you cue, touch, or help the patient, the more
the patient needs you
Motor Learning Recipe for Success: Capability
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• Overtraining: pressure, speed, accuracy, or physical demand
• Dual task: competition for attention during performance
• Error-induced training: learner’s impairments are magnified/increased
Continuum of Rehabilitation “Loading”
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Error Dosage in Speech/Swallow
Source or mode Example
Physical demand• Long conversation or concept to relay• Texture of food or combined textures• Alliterations
Complexity
• Multiple textures on the plate• Several people talking at once• Background noise irrelevant• Malfunctioning hearing aid
Distractions• Recalling directions while sightseeing• Playing cards and visiting• Watching a novel sporting event
Pressure• Speaking in front of people• Recent aspiration pneumonia• Limited time to eat
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Error Dosage in Mobility
Source or mode Example
Physical demand
• Speed demands• Weights (ankles)• Incline• Duration
Complexity • Carrying a tenuous object (water)• Narrow pathway/accuracy
Distractions• Retrieving an item from a purse/wallet• Holding a conversation• Listening to walking directions
Pressure• Continence• Safety for self/others• Timing to cross a street/reach a door
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Error Dosage in ADLs
Source or mode Example
Physical demand• Speed demands• Cushioned surface• Height of sitting surface
Complexity
• Challenging buttons• Particular look/appearance (hair, clothes)• Layers• Zippers
Distractions
• Pain• Conversation• Shopping list• Appointments
Pressure• Timing to appointments• Availability of transport (bus, other)• Continence
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• Ultimately, the brain must see a need to survive, protect, compete, improve
• If there is no ___, then there is no stimulus to continue to improve– Challenge – Chance – Expectation – Success
Growth Stimulus
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Where Are Procedural Memories Processed Before Stroke?
Procedural memories with attentional supervision to task and environmental constraints
– Swallowing– Speaking– Walking– Dressing – Hygiene
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Where Do Procedural Memories Reemerge After Traditional Stroke Rehab?
• Therapists direct cues internally; patients focus on body parts
• Is it truly beneficial to direct cues to the particulars of– Swallow?– Walking?– UE function?
Robertson, 2009
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Where Is Swallowing ProcessedBefore Stroke?
The swallow experiment, Part 1
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Where Do These Tasks Reemerge After Traditional Stroke Rehab? (Cues, Attention Based)
The swallow experiment, Part 2
Robertson, 2009
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• Attend to relevant stimuli given environment and task• Extinguish, ignore, or filter extraneous stimuli • Self-monitor function (safety, communication) and
prioritize• Tolerate more distractions with less primary task loss• Avoid environments that are too much to manage• Improved motor skill automaticity in DT training• DT modalities include distractions in four forms
(modes):Cognitive Visual Auditory Manual
Dual-Task Training: Overarching Themes
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How Is Dual-Task Tolerance Improved?
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• Task specificity to the type of distraction (mode)• Intensity matters
• Timing of learning/relearning motor skill matters
• Cognitive capacity matters• Novelty matters
• Complexity matters• Prior experience/procedural learning matters
Principles/Tenets of Dual-Task Rehabilitation
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Attentional and Procedural Networks
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Cognitive Visual Auditory Manual
Intervene if the screening is positive by modality – Overlapping of modalities will happen– Testing is not intended to be task-specific or functional– Test each primary and distracter alone– Dual task can enhance primary motor– To cue or not to cue?
• Prioritization must be consistent
Screening and Intervening: DT Tolerance Across Four Modalities of Concurrent Tasks
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• Screening• Specificity: exposure to conditions/environments• Dosage• Intensity: sufficient challenge to create a dosage• Awareness
• For a comprehensive review of dual task, see my other pre-recorded webinar titled: • Dual Task Training in Stroke Rehabilitation: Recovering
Automaticity in Gait, ADL, Swallow and Other Procedural Memories
DUAL TASK: Basics
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• Automaticity is the relative ease with which something is processed– This considers consistency, adaptability, fatigability, and
the degree of concentration or attention required
• Automaticity is related to the experience of a performer, their relative ease, and degree of habit vs. skill
• Your patient recovering from acute or chronic stroke can and needs to improve automaticity. Why?
Automaticity
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Your patient recovering from acute or chronic stroke can and needs to improve automaticity. Why?
– Automaticity indicates degree proficiency (procedural skill)
– Procedural memories do not require cognitive resources– Skills and habits (procedural) are less prone to variability– Procedural memories are more resistant in dementia– When life gets busy, stressful, or dangerous, movements
that do require cognitive input are subject to failure
Automaticity (cont.)
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Retraining Automaticity – not limited to gait OR treadmill!
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Automaticity in Walking
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Automaticity in ADLs
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Automaticity in Conversation
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Automaticity in Avocation
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Automaticity in Swallow
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• Introducing a distraction during the act of relearning an overlearned task can aid in re-forming procedural memories
• Devoting full attention to a motor task creates a dependence on attention that can be dangerous to depend on in time
Studer M, Winningham R: Recovering the Procedural Memory After Stroke. 2017
Dual Task Improves Learning? How?
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• Constraint-induced reduction of cognitive resources• Forced use of implicit/procedural memory centers
• Improved primary resource of attention
• Compensatory reprioritization through awareness• Neuroplasticity of motor control
Dual Task Improves Learning? How? (cont.)
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• Optimizing• Performance• Through• Intrinsic• Motivation• Attention for • Learning
• Autonomy• Enhanced expectancies
• External focus
Resource: OPTIMAL Theory of Motor Learning
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• Any patient can improve anytime– See latest research
• One year?• Five or more?
• Measurement priority• Requires consistency and intensity
• RIPE = Repetitions, Intensity, Promise and Error
Psychological Effects of Chronic Stroke
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Overcoming disbelief, “I am done improving”– Measuring change– Motivating from within– The dosage of intensity
Case Studies: Chronic Stroke
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• Incentives• Constraints
• Rewards
Neuroplastic Stimuli Reiterated
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Chapter Six
Introduction to Advanced Concepts
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• Sensory neuroplasticity for the UE and LE• Dual-task training advanced concepts• Retraining automaticity AND adaptability
• Constrained learning and forced use applications• Applications in overtraining:
HIIT, error-enhanced learning, and amplifying error• Individualized success ratios: successive
approximation• OPTIMAL motor learning theory applications, video
• Frail and severely impaired patient recovery
Introduction to Advanced Concepts
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Opportunistic Use Therapy
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• Combine a standardized or objective measure with everyday distracters
• Compare performance with/without distracter
• Compare performance pre/post intervention• The result is your functional attention or dual-task cost
Dual Task: An Objective Measure of Attention?
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Reverse the secondary changes of– Deconditioning (strength)– Deconditioning (endurance)– Visual dependence– Imbalance from fear and deconditioning– Flexibility-led biomechanical impairments – Maladaptive sensory strategies
Chronic Stroke
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• Personalization• Functional specificity
• Challenge
• Test• Prediction
• Reporter• Gamification
• Vicarious experiences
Methods to Maximize Attention
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• Measurement is critical• How do I measure the frail patient?
• Frail patient considerations
The Frail and Very Elderly Stroke Patient
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• Objective recordings that can be reproduced to prove real changes within a patient’s case
• Timed bed mobility
• Timed five times sit-to-stand• MCHST: unassisted sit-to-stand height
• 10-foot wheelchair propulsion• Timed standing endurance
The Frail and Very Elderly Stroke Patient: Measurement
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• Building habituation/capacity• Awareness for self, task
• Problem-solving = prioritizing, filtering
• Utilizing other cerebral resources: memory autonomics procedural shift
• Rebuilding motor automaticity/procedural memory
Function and Physiology of Dual-Task Tolerance
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Chapter Seven
Summary
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• Repetitions• Intensity
• Goal direction
• Motivation– Motivation can be considered a combination of goal
direction and interest, leading to intensity
• Autonomy• Expectations of success
• Personality/tolerance
Evidence-Based Considerations for Normal and Impaired Learning
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• Provide the brain with repeated exposure in an attempt to reinforce neuroplastic changes of synaptogenesis and synaptic efficacy
• Repetitions alone are often insufficient due to matters of intensity and reduced attention if delivered in blocked practice
Repetitions
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• Providing sufficient stimulus for change• Intensity does not need to be directly correlated to
exertion as it can come from skill, difficulty, accuracy, or consequence (fall, embarrassment, etc.)
• Intensity without success can inhibit learning
Intensity
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• Enables a learner to channel efforts toward what is to be accomplished, rather than how
• Promotes movement organization around procedural memory consolidation, and reduces the role of attention on specific body parts mid-task
• Early emphasis on goal direction at the complete exclusion of movement specifics can inhibit the benefit of advice, observation, and kinesthesia
Goal Direction
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• Greater motivation often leads to improved neuroplastic stimulus through intensity, attention, and (after successful trial) dopaminergic rewards
• Motivation can dysfunctionally lead to addiction
Motivation
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• Choice in task type, difficulty, setting, or order can improve investment and attention in practice or function
• Pathways of motivation, attention, and intensity allow autonomy to influence learning and neuroplasticity
• Excessive options of autonomy can agitate some patients and discount the authority of therapists
Autonomy
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• Learners that expect success are primed to repeat past successful strategies and repetitions, leading to consolidation of learning and neuroplastic change
• Dopaminergic reward systems are fulfilled with enhanced expectancies toward a common goal
• When practice or competition includes expectations of success, yet the resultant outcome includes too many repetitions (personality dependent), learning can be blunted and systems depressed
Expectations of Success: Enhanced Expectancies
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• Individual attributes influence response to challenge, tolerance of intensity, tolerance of error, and reward systems
• Practice without sufficient incorporation of individual personality traits may not provide optimal dosage and can cause either boredom or agitation
Personality/Tolerance
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• Overcoming the “bad habits” with intensity and a forced-use approach (sensory dependence, guarding movements)
• This is one of the main reasons you can help any stroke patient improve
Learned Nonuse and Dysfunctional Neuroplasticity
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• [email protected]• YouTube
– Rehabilitation NWRA
• www.mikestuder.com• Facebook
– NWRehab
Mike Studer, PT, MHS, NCS, CEEAA, CWT, CSST
Not for reproduction or redistribution
Break
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Question and Answer Session
Maximizing Functional Recovery Across the Continuum: Acute & Chronic Stroke
1
Bibliography
MedBridge Maximizing Functional Recovery Across the Continuum: Acute & Chronic Stroke
Mike Studer, PT, MHS, NCS, CEEAA, CSST, CWT
1. Saeed Ghorbani (2019) Motivational effects of enhancing expectancies and autonomy for motor learning: An examination of the OPTIMAL theory, The Journal of General Psychology, 146:1, 79-92, DOI: 10.1080/00221309.2018.1535486
2. Chua, Lee-Kuen & Wulf, Gabriele & Lewthwaite, Rebecca. (2018). Onward and upward: Optimizing motor performance. Human Movement Science. 60. 10.1016/j.humov.2018.05.006.
3. Wulf, G., Iwatsuki, T., Machin, B., Kellogg, J., Copeland, C., & Lewthwaite, R. (2018). Lassoing Skill Through Learner Choice. Journal of motor behavior, 50 3, 285-292 .
4. Lewthwaite, Rebecca & Wulf, Gabriele. (2017). Optimizing motivation and attention for motor performance and learning. Current Opinion in Psychology. 16. 10.1016/j.copsyc.2017.04.005.
5. Wulf, Gabriele & Lewthwaite, Rebecca. (2016). Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning. Psychonomic Bulletin & Review. 23. 10.3758/s13423-015-0999-9.
6. Carvalho, R, Azevedo, E, Marques, P, Dias, N, Cerqueira, JJ. Physiotherapy based on problem‐solving in upper limb function and neuroplasticity in chronic stroke patients: A case series. J Eval Clin Pract. 2018; 24: 552–560. https://doi.org/10.1111/jep.12921.
7. Zastron, Tania & Kessner, Simon & Hollander, Karsten & Thomalla, Götz & Estelle Welman, Karen. (2019). Structural connectivity changes within the basal ganglia after 8 weeks of sensory-motor training in individuals with chronic stroke. Annals of Physical and Rehabilitation Medicine. 10.1016/j.rehab.2019.02.002.
8. Ploughman, Michelle & Eskes, Gail & Kelly, Liam & Kirkland, Megan & Devasahayam, Augustine & Wallack, Elizabeth & Abraha, Beraki & SM Mahmudul, Hasan & Downer, Matthew & keeler, Laura & Graham, Wilson & Elaine, Skene & sharma, ishika & Chaves, Arthur & Curtis, Marie & Bedford, Emily & S Robertson, George & Moore, Craig & McCarthy, Jason & MacKay-Lyons, Marilyn. (2019). Synergistic Benefits of Combined Aerobic and Cognitive Training on Fluid Intelligence and the Role of IGF-1 in Chronic Stroke. Neurorehabilitation and neural repair. 10.1177/1545968319832605.
9. Aerobic Training Efficacy in Inflammation, Neurotrophins, and Function in Chronic Stroke Persons: A Randomized Controlled Trial Protocol (2019). Oliveira, Daniela Matos Garcia et al. Journal of Stroke and Cerebrovascular Diseases, Volume 28, Issue 2, 418 – 424.
10. Rubio Ballester B1, Maier M2. A critical time window for recovery extends beyond one-year post-stroke. J Neurophysiol. 2019 May 29. doi: 10.1152/jn.00762.2018.
11. Wulf, G. & Lewthwaite, R. Psychon Bull Rev (2016) 23: 1382. https://doi.org/10.3758/s13423-015-0999-9.
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12. Guadagnoli, Mark & D Lee, Timothy. (2004). Challenge Point: A Framework for Conceptualizing the Effects of Various Practice Conditions in Motor Learning. Journal of motor behavior. 36. 212-24. 10.3200/JMBR.36.2.212-224.