Neuroplasticity in the Clinic

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Neuroplasticity in the Clinic: U(lizing Evidence To Maximize Par(cipa(on in Occupa(on for Individuals With Stroke

Christine Griffin, OTR/L MS,BCPR Ohio State University Medical

Center – Dodd Hall [email protected]

Evolu(on of Rehab Interven(on

•  Evidence Based Prac(ce – Are we able to prove that what we are doing is effec(ve?

•  AOTA Centennial Vision •  Closely examine what our interven(on for survivors of stroke require and what is effec(ve

Neurofacilitation Techniques

•  Brunnstrom’s Movement Theory – Limited Evidence

• Wagennar et al. (1990) –  Brunnstrom phases vs NDT phases, n = 7 –  One par(cipant performed be]er with Brunnstrom than NDT

•  Sawner & LaVigne, 1992 –  Studies cited to support the approach were published between 1898-‐1960


•  Propriocep(ve Neuromuscular Facilita(on – Smedes, 2006 Systema(c review of 4 RCT

•  In a home and structured program Inclusive PNF is effec(ve, treadmill training is more effec(ve than PNF on gait, and NMES is more effec(ve than PNF on hand func(on

•  Rood – No Evidence

Neurofacilitation Techniques •  NDT/Bobath

–  Langhammer et al, 2000 •  Motor learning be]er than Bobath

–  Tang et al, 2005 •  Task oriented approach be]er than NDT

–  Hafsteonsdodr et al, 2005 n=324 •  Bobath vs standard therapy •  No difference, Bobath group had more treatment sessions

–  Systema(c Review –  Kollen et al. (2009) Bobath Concept is not superior to other

approaches –  Rao (2011) Lack of effec(veness of the Bobath approach when

compared with a task-‐oriented approach


•  Proprioceptive Neuromuscular Facilitation, Rood, and Brunnstrom Approach –  Evidence “sparse and inconclusive”

(Sabari, 2010) –  Based on outdated views of motor recovery and motor control

(Ma & Trombly, 2002; Pollock, Baer, Pomeroy, & Langhorne, 2007; Steultjens et al., 2003)

•  Neurodevelopment Treatment –  No evidence of significantly better outcomes for NDT when

compared with other treatments to improve upper limb motor function (Luke, Dodd, & Brock, 2004; Packi, 2003)

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Shig in Rehabilita(on Approach

•  Self Examina(on •  Interven(on supported by Evidence and Research

•  Paradigm shig from tradi(onal theories to Neuroplas(city

Neuroplasticity – What is it?

•  Neuroplas(city à Changing the brain •  Capability of CNS to alter func(on and structure in response to use and motor learning

•  Reorganiza(on of undamaged systems in the brain

•  The brain responds to func(onal/ environmental demands

•  Occurs ager Repe((ve Prac(ce (Lundy-‐ Ekman, 2007, Kass, 1991, Donoghue et al, 1991)

Neuroplasticity

•  Borders of neuro mapping are not defined – Brain is moldable according to the will and

actions of the individual •  Nudo (2001)

– Adaptive plasticity in motor cortex – Functional and structural dynamic nature of

the cerebral cortex

Neuroplasticity •  Possible Explanations

– Areas of the brain assume functions that were once the responsibility of a damaged area of the brain

– Areas of the brain lay dormant until needed to assume functioning for damaged regions

–  Creating new pathways for the connections between neurons

(Gutman, 2008)

Repetitive Practice

•  High Intensity/ High Repetition → Cortical Changes

•  Motivational Strategies for Patient – Self control vs. External Control

•  Patient education –  Importance of intensity of repetition –  Intensive HEP

Learned Non- Use

•  Decrease is muscle/ motor activity → decrease in function → frustration → avoidance of activity

•  What happens cortically? •  Kleim (1998)

– Motor cortex representation diminishes with immobilization beyond nine days

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Neuroplasticity is Skill/ Activity Dependent

•  Nudo, 2001 – Plasticity is limited to behavioral experiences

•  Nudo, 2003 – Plasticity of the motor cortex are skill-

dependent rather than simply use dependent. •  Cauragh, 2005

– Upper extremity gains evolve from motor experiences and activity-dependent interventions

Chronic Recovery

•  Thickbroom, 2004 –  Purpose: Investigate the relationship between

changes in motor cortex organization and degree of motor function after stroke

–  Subjects: 27 pt’s with upper limb motor deficits up to 23 yrs after onset

–  Intervention: The hand’s corticomotor area was mapped with transcranial magnetic stimulation. Motor Assessment Scale and grip strength measurement were used as functional assessments. Task oriented treatment was provided

Thickbroom (Clin Neurophysiol 2004)

– Results: After treatment, motor maps of the hand showed displacement in 17 pt’s. Ten pt’s showed normalization of corticospinal conduction and a positive correlation between the magnitude of the map shift and grip strength in the affected hand.

– Conclusion: The present findings provide evidence that cortical plasticity and reorganization occurring after a stroke is functionally significant.

Neuroplasticity

•  Active repetitive task oriented motion

Methods of Neuroplasticity

•  Constraint Induced Movement Therapy •  Task Based Practice •  Mental Practice •  Mirror Therapy •  NMES •  Bilateral Training

Constraint Induced Movement Therapy (CIMT)

•  Forced use to counteract learned nonuse – Pa(ent unsuccessful with use of affected limb, so would stop ini(a(ng use of limb during tasks

•  Restraint of unaffected hand/ arm

•  Motor inclusion criteria – 10 MCP extension and 20° wrist extension – Distal func(on is a cri(cal factor

(Wolf, 2006)

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Constraint Induced Movement Therapy (CIMT)

•  Main factor – Massed prac(ce during repe((ve func(onal ac(vi(es •  Restric(on of less effected arm 90% of day during a 2 week period

•  Par(cipa(on in upper limb therapy program 6hrs/day during the 2 week period

•  Shaping is very important (picking appropriate ac(vi(es) –  Select tasks that address the motor impairment and pa(ent is able to carry out parts of the motor sequence

–  Has direct rela(onship to success of treatment (Taub et al, 1999)

EXCITE: Trial, Wolf et al, 2006

•  EXCITE: Extremity Constraint – Induced Therapy Evaluation – Multi-Center, 222 subjects, over 3 yrs – 6 hrs/ day, 5 days/ week, 2 weeks – Significant improvement in Wolf Motor

Function Test and Motor Activity Log – Lasted 24 months later

CIMT

•  Neuroplas(cty –  Induces cor(cal representa(on of the affected upper limb

•  Effects sustained for at least 2 years ager interven(on •  Beneficial treatment for pa(ents with some ac(ve wrist

and hand mo(on •  Taub et al, 2006 •  Boake et al, 2007 •  Dahl et al, 2008 •  Myint et al, 2008

Modified CIMT

•  Dosing – Restric(on of less effected arm 5 hrs/day, 5 days/wk

– Par(cipa(on in upper limb therapy program 1 hr/ day, 3 days/ week, 10 weeks

•  mCIMT performed be]er on Fugl-‐Meyer and Ac(on Research Arm test than “usual care” following treatment and at 12 month follow up

(Page et al, 2002, 2004, 2005)

CIMT -‐Timing •  Teasel, ebrsr.com •  Acute

–  “There is conflic(ng evidence of benefit of CIMT in comparison to tradi(onal therapies in the acute stage of stroke”

•  Chronic –  “There is strong evidence of benefit of CIMT and mCIMT in comparison to tradi(onal therapies in the chronic stage of stroke. Benefits appear to be confined to stroke pa(ents with some ac(ve wrist and hand movements, par(cularly those with sensory loss and neglect”

Task Oriented Approach

•  Based on systems model of motor control and theories of motor learning

•  Therapist is a teacher of motor skills – Select contextually appropriate func(onal tasks – Vary tasks to increase transfer of learning – Structure the environment the condi(ons of the task are present

– Provide feedback (Carr and Shepherd, 2003, and Gen(le, 2000)

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Posi(ve Effects of Task Oriented Approach on Impairment level and Func(on

•  Barker et al., 2008 •  Blennerhasset et al., 2004 •  Caraugh et al., 2006 •  Michaelson et al., 2006 •  Nelles et al.,2001 •  Stinear et al., 2008 •  Theilman et al., 2004 •  Winstein et al, 2004

Task Oriented Approach

•  Hubbard et al, 2009, Systema(c Review – “We recommend that task-‐specific training be rou(nely applied by occupa(onal therapists as a component of their neuromotor interven(ons, par(cularly in management related to post-‐stroke upper limb recovery”

Task Based Practice Opportunities

•  Improved function of hemiplegic upper limb when using functional objects and activities vs. performing similar movement sequences in the absence of task performance –  (Wu, Trombly, Lin, and Tickle-Degnen, 1998; Trombly and

Wu, 1999; Wu, Trombly, Lin, and Tickle-Degnen, 2000; Fasoli, Trombly, Tickle-Degnen, and Verfaellie, 2002; Smedley et al., 1986; Winstein et al., 2004)

•  Client’s are not making connection between non-functional activities and functional outcomes

Occupa(onal Therapist Determines

•  Each client’s current poten(al to relearn motor and cogni(ve skills

•  How to match task-‐based challenges to each person's current poten(al

•  How to modify each person’s environment to provide the appropriate balance between challenge and compensa(on –  (Sabari, 2011)

Real Life Challenges

•  Busy caseload •  Produc(vity standards •  Limited (me •  Challenging pa(ents and family members •  Non-‐produc(ve (me: Documenta(on, mee(ngs, in-‐services, etc.

Occupa(on Kits •  Treatment kits made prior to treatment session •  Lower Level – Gross Grasp

–  Placing ea(ng utensils in organizer –  Placing magazines in organizer –  Table sedng for 8 –  Removing dishes from drying rack –  Placing tools in tool box –  Placing CD’s in rack –  Placing cooking utensils in tall container –  Placing folded socks in bin/ drawer –  Placing cans/jars on shelving

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Occupa(on Kits Higher Level – Bilateral coordina(on and fine motor coordina(on

–  Folding clothes in laundry basket

–  Hanging clothes on retractable clothes line

–  Packing a suitcase with clothes –  Pudng ba]eries in remote

control –  Pudng toilet paper on holder

and pull off a sheet –  Installing toilet paper holder

on base –  Sanding plywood –  Installing a door knob –  Installing a smoke alarm

–  Sor(ng and assembling assorted sized nuts and bolts

–  Separa(ng and placing play money in wallet

–  Coins in coin bank or change purse

–  Medica(on into pill organizer –  Wrapping a gig/ package –  Stuffing envelopes –  Sor(ng paper clips –  Cudng and stapling paper –  Sor(ng coupons –  Scrap booking

Mental Practice - Imagery

•  Rehearsing task or series of tasks mentally – Cognitive Rehearsal

•  No physical activity •  Athletes – Sports psychology •  Supplement conventional therapy •  Used at any stage in recovery

•  (Braun et al., 2006, & Jackson et al., 2001)

Mental Practice

•  Activates the musculature in the same pattern that correlates with imagined movements – measurable on EMG

•  Activates the cortical representation in the same pattern that correlates with imagined movements – measurable on fMRI

•  Improves learning & performance •  Reorganizes motor cortex - Neuroplasticity

Mental Practice

•  Most plausible mechanism to explain – “Stored motor plans for executing movements

can be accessed and reinforced during mental practice”

(Page, 2001)

Mental Practice – How is it done?

•  Audio recording 1.  Period of deep relaxation (3-5 min.) 2.  Mental Practice Portion

•  Involve every aspect of the experience including size of room, and full description of the movement including the feel of the movement.

•  “Imaging you are sitting in your favorite chair. The room is quite. There is a table in front of the chair” “imagine there is a cup of that table with fresh apple juice in it. Feel yourself reaching for the cup. Feel the weight of your arm as you reach out. Feel your elbow straightening and your wrist extending. Your hand opens, and your fingertips touch the cool china cup” etc.

3.  Practice in the real world. Three listening sessions to one practice session

(Levine, 2009)

Page et al 2000, 2001, 2005, 2007

•  Method – Tape recorded guided imagery + traditional

therapy vs. audio placebo + traditional therapy – Mentally perform series of tasks

•  Ex: reach for cup – 20 min – 1 hr/ day, 2-5 sessions/ week, 4-6

weeks •  Results

– Significant improvement in Fugl-Meyer and Action Research Arm Test Scores

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Liu et al, 2005

•  Mental imagery of specific task + traditional therapy vs. Functional training of specific task + traditional therapy

•  Method – Over 3 weeks, trained to perform 3 sets of

daily tasks for 1 hr./ day •  Results

– Mental imagery group had higher ADL function than functional training, no difference in Fugl-Meyer scores

Visual Mental Practice Ertelt et al, 2007

•  Method – Watch video of upper limb movement &

perform movement VS. watch video of geometric shapes & perform movement

•  Results – Significant improvement in video group of

upper limb movement that sustained for at least 8 weeks

Ietswaart et al, 2011

•  3 groups •  Motor mental rehearsal of upper-limb motion vs

placebo non-motor mental rehearsal vs usual care •  45 min/ day, 3 sessions/ week, 4 weeks •  No difference among groups on Ac(on Research Arm Test

Mental Prac(ce Evidence

•  Cocharane review, 2011-‐RCT’s only – “Limited evidence that mental prac(ce in addi(on to other rehabilita(on therapies is effec(ve compared with the same therapies without mental prac(ce”

Mental Prac(ce Evidence

•  Nilsen, et al., 2010 –  “Consistent and posi(ve outcomes have been documented, including decreased upper extremity impairment, increased upper extremity func(on, and increase in everyday use of the limb outside of structured therapy”

•  Jackson, 2001 –  “Data from psychophysical, neurophysiological, and brain imaging studies support the existence of a similarity between executed and imagined ac(ons”

Systematic Reviews •  Teasel, 2011 ebrsr.com

–  “There is conflicting evidence that mental practice may improve upper-extremity motor and ADL performance following stroke”

–  “Mental practice may result in improved motor and ADL functioning after stroke”

•  Nilsen, et al., 2010 –  “When added to physical practice, mental

practice is an effective intervention. Further research is warranted to determine who will benefit, dosing, and most effective protocols.”

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Mirror Therapy

•  Uses visual feedback about motor performance to improve rehabilita(on outcomes

•  Viewing the reflec(on of unaffected arm in the mirror may act as a subs(tute for the decreased or absent propriocep(ve input

Mirror Therapy •  Pa(ent seated close to table with a mirror (35 cm x 35 cm) placed ver(cally

•  Involved arm behind mirror, noninvolved in front of mirror

•  Complete movements with noninvolved arm •  Pa(ent watching movements of noninvolved seeing the reflec(on of the hand mo(on projected over the involved hand

•  Pa(ent asked to try to do the same movements with the involved hand while moving the noninvolved

•  (Yavuzer et al, 2008)

Mirror Box

Photo from personal collec(on of Chris(ne Griffin. Used with permission.

Mirror Therapy -‐ Evidence •  Yavuzer et al, 2008

–  Standard therapy + mirror therapy vs. standard therapy – Mirror therapy group had increased hand func(on and FIM scores compared to standard therapy at 4 weeks 6 months

•  Dohle et al, 2009 –  Standard therapy + mirror therapy vs. standard therapy –  Pa(ents with distal impairment only – Mirror therapy group regained more distal func(on, improved recovery of surface sensibility, s(mulated recovery from hemineglect

Mirror Therapy -‐ Evidence •  Michielsen et al, 2011

–  Standard therapy + mirror therapy vs. standard therapy

– Mirror therapy group had increased Fugl-‐Meyer scores compared to standard therapy, but did not persist at follow up. No differnece found in ARAT or ADL func(on

•  Teasel, 2011 ebrsr.com –  3 RCT’s only –  “There is conflic(ng evidence that mirror therapy improves motor func(on following stroke and moderate evidence that it does not reduce spas(city”

Motor Recovery and Electrical S(mula(on ager Stroke

Low

Low

High

High

Client centered

Task Specific

Cyclic E-stim

EMG- Triggered

E-stim

Functional E-stim

(Page, 2010)

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Cyclic Neuro Muscular Electrical S(mula(on (NMES)

•  Contracts muscles on a preset schedule, does not require active participation

•  Goals – Decrease spasticity – Muscle strength – Reduce edema –  Improves motor impairment in mild to

moderate stroke (Hill-‐Herman, 2010)

Electro Myograph Generated (EMG) -‐ Triggered

•  Must actively move to reach established threshold to “trigger” NMES to activate

•  Outcome –  Increased function – Decreased motor impairment –  Increase ability to concentrate (specifically on

using the affected side of the body) – Enhance behavioral training (active pt

participation) – Marked increase in reaction time –  Increase AROM

(Hill-‐Herman, 2010)

EMG – Triggered NMES

•  How does it work? –  Set s(mula(on intensity and EMG threshold –  Electrodes sense trace contrac(on/muscular a]empt –  Device rewards pa(ent with s(mula(on –  Begin sequence again…

(Hill-‐Herman, 2010)

EMG – Triggered NMES

Photos from personal collection of Christine Griffin. Used with permission.

EMG – Triggered NMES Video Exercise & Functional Use

Videos from personal collec(on of Chris(ne Griffin. Used with permission.

Func(onal Electrical S(mula(on (FES)

•  Cyclic NMES during functional movements and functional activity

•  Goals: –  Improve or restore the grasp and manipulation functions

required for typical ADL task –  Facilitate neuromuscular reeducation –  Regulate muscle tone (decrease spasticity) –  Prevent atrophy- muscle strengthening –  Initiate and regain voluntary motor functions (muscle

reeducation) (Hill-Herman, 2010, Popovic et al, 2002)

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FES purpose

•  Adaptive •  Similar to an adaptive device to be used in order to

engage in functional activity

•  Therapeutic •  Used during therapy in order to retrain brain and

muscles how to work and how to work together

•  Supplemental •  Can be used above and beyond what is done in

treatment and can be combined with other interventions

(Hill-Herman, 2010)

Traditional FES

•  E-Stim applied to muscles to elicit limb movement in specific sequence during functional tasks

•  NMES units, splints, and other supports may be used

•  Patient actively moves limb to engage in activity (task specific and client centered)

Neuroprosthetic for FES

•  Orthoses with embedded electrodes •  Custom fit to individual

– Extensor panel – Flexor panel – Thumb electrode –  Inserts – Straps

Neuroprosthetic for FES

Photos from personal collection of Christine Griffin. Used with permission.

Video for FES Functional Use & Gravity Eliminated AAROM

Videos from personal collec(on of Chris(ne Griffin. Used with permission.

NMES Evidence –Systematic Review

•  “There is strong (Level 1a) evidence that FES treatment improves upper extremity function in acute and chronic stroke” (Teasell, 2011)

•  “There is moderate evidence that EMG-triggered NMES is not superior to cyclic NMES” –  Majority of studies included acute and chronic stages

of stroke –  “Hypothesized that there may be a critical 5 week

time window following stroke which dexterity is most likely to be gained”

(Meilink et al, 2008)

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Active Scapular Stability Home Exercise Program

(For patient with low active mobility in upper limb)

Images from Ohio State University Medical Center. Used with permission

Gravity Eliminated AAROM – Pre-Functional Level

•  For patient with low active mobility in upper limb

•  Stability of scapula on thoracic wall with emphasis on upward rotation

•  Improves shoulder function and subluxation

Photos from personal collec(on of Chris(ne Griffin. Used with permission.

Gravity Eliminated AAROM – Pre-Functional Level

•  Shoulder abduc(on •  Elbow flexion and extension

•  Supina(on/ Prona(on •  Gross grasp

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