Lambeck (2013) Massed Practice (ECEBAT)
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Transcript of Lambeck (2013) Massed Practice (ECEBAT)
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Massed practice in neurological rehabilitation
Johan Lambeck; in cooperation with Marcel Hulselmans, Edina Sziráki, Péter Pribély,
Nico van den Beukel, Joost Spelt
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Programme
• Introduction Johan Lambeck
• Overview of treadmill research and applications Marcel Hulselmans
• Explanation of the possibilities of the Aquawallgym Edina Sziráki
• A circuit in the pool with various pieces of equipment and activities „freely“ in the water Johan Lambeck, Marcel Hulselmans, Edina Sziráki, Péter Pribély, Nico van den Beukel, Joost Spelt
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Motor (re)learning in neurology:
How to rewire the brain
• What is motor (re)learning? • A theoretical concept • Principles • Massed practice • Enriched environment • Why water?
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Motor learning = • Achieving a "relatively permanent” change towards
skilled motor behavior, resulting from practice, also capable of error-detecting and responding to the
constraints of the environment (Schmidt & Lee 1999)
• An effective way of learning is by offering variability of skill performance by changing context and (bio)mechanical constraints (Schmidt and Lee)
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Practice
– Achievement depends on structure (quality and quantity) of practice and feedback as well on the interaction between the person, the task and the environment • Dynamic Systems Model / DSM (Newell 1986)
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DSM
Motor control
Task
Envi
ronm
ent
Newell 1986:
The specific constraints of the environment can therapeutically influence the patient‘s motor behavior
The pool
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To prevent or to change these: Increase movement frequency and stress the neuromotor system. The system gets instable and possibly adapts /trains. Enrich the environment in order to stimulate the neuromotor flexibility
Therapy >> distributed massed practice in an enriched evironment
Bad habits In neurology, specific motor behavior solutions will appear and persist a „bad habit“ (Beek, 2012).
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Distributed massed practice
• An intervention with repetitive practice as the primary therapeutic factor, with distributed rest periods (Taub 2001, Murray 2003)
– A known example is constraint induced movement therapy
• Goal: functional cortical (brain) reorganization according to Taub & Nudo by e.g synaptosis, dendritogenesis and angiogenesis
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Research
– increased somatosensory activity in the same and adjacent maps Beekhuizen 2005, 2008
» 2 h, 4 days/wk continuous repetition of tasks in 5 categories, 25 min per category (incomplete SCI handfunction
– Large (ss) improvements in various walking - and balance tests Marklund 2006
– chronic post-stroke patients 6 h, 5 days/week, 2 weeks. Random choice of cycling, pool training, functional strength training in different start positions (sitting down, stand up and lay down), weight-bearing in different directions, stair training without use of banisters, indoor walking/outdoor walking on uneven surfaces.
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Research: case study
– Sign. results in (anticipatory) balance with less falls and more symmetrical weight-bearing
– Vearrier & Shumway-Cook 2005: 1 patient post-stroke – 6 h/day, 5 days/week, 2 weeks. Contents:
• functional mobility: ambulation and upright static and dynamic balance tasks
• addressing impairments such as limitations in strength and ROM. • Subjects’ daily regimen consisted of 70% functional training, 20%
impairment related intervention, 5% disability level activities, and 5% intermittent rests
• Equipment that also was used: bicycle, treadmill, obstacles
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Contextual interference
• Contextual interference is a technique that involves making the practice environment more difficult by having learners practice several skills interchangeably and randomly
• Random (= unpredictable) variability in the form of
irrelevant movement components, necessary for good performance
– Always some minutes for every skill, but sequence at random
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Stochastic resonance W. Schöllhorn (2010)
• There is no ideal movement and we cannot correct toward that ideal movement
• Mistakes are important: these give differences with information about the best way to perform a task
• Stochastic resonance = adding bias can show a below-threshold signal > variations in environment and task make the central nervous system react. This cns response continues after the actual training.
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Environment enrichment
• Refers to conditions that facilitate enhanced sensory, cognitive, affective and motor stimulation, Nithianantharajah & Hannan 2006
• Environmental enrichment stimulates the hippocampus to produce BDNF = brain derived neurotrophic factor Sao 2010
– BDNF production is also augmented during bicycling in water by patients with Multiple Sclerosis Bansi 2012
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Keywords:
Somato-sensory stimulation
Modulation of attention
Exploratory movements
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Practice needs to be
• Challenging / demanding /motivating
• Repetitive, yet variable
• Attention taking
• Arousal stimulating
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Therapy
• Distributed massed practice with contextual interference in an enriched environment by random application of variable, challenging, arousing, motivational and attractive exercises.
• Would a massed practice set-up in the pool also reach the above mentioned idea?
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Why water in (early) neuro-rehab?
• Slow instability – water as a perceptual reference surface – The patient has to react
• Freedom of movement – High dose of information and motor output
• Distributed massed practice
– Patient can be dynamic, but grade intensity: • Easier to run, jump, sneak, walk and talk • important also for the cardiovascular/pulmonal
systems
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The environment provides
• Support – Hands-free: space between patient and therapist =
independence – Less force needed to elicit muscle activity
• Safety – No risk to fall, but still a challenge to balance – Time to think and to react
• Input to the CNS changes – We like it: Water = fun and motivates
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The pool
• A circuit in the pool with various pieces of equipment and activities „freely“ in the water
– Pooltrack treadmill – Underwater bicycle – Obstacle course – AquawallgymTM
– Stations with picto‘s about Halliwick activities – Aquatwister – Aquastrider – Aquawalker
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Aquagym: aquaclimber, aquastrider, aquatwister
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Free Halliwick like exercises
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Thank you for your attention
and let‘s continue