Presented by: Megan Setlock, MS, OTR/L; msetlock ... Million Dollar Question.pdfproportion of motor...

Presented by:Megan Setlock, MS, OTR/L; [email protected] Cupka, COTA/L, CBIS; [email protected]

Disclosure Neither the presenters nor Sheltering Arms

have financial interests in the technologies, companies, or products discussed in this presentation.

For Presentation Handout:www.shelteringarms.com/vota2014

Property of Sheltering Arms. Do not use or alter without permission.

The participant will be able to identify neuroplasticity principles and the recommended number of repetitions associated with cortical reorganization.

The participant will be able to discuss current research trends regarding number of repetitions achieved in traditional therapy on average in inpatient rehabilitation settings.

The participant will be able to identify the benefits of advanced technologies through the use of a Clinical Practice Guideline to address repetitions required for neurologic recovery.


“The various ways in which the nervous system can change its function as a result of training, or in response to injury” (Henson & Keogh, 2010, p. E54).

“Neural plasticity is believed to be the basis for both learning in the intact brain and relearning in the damaged brain that occurs through physical rehabilitation” (Kleim & Jones, 2008, p. S225).


Extrinsic factors: Motor learning Motor relearning Electrical stimulation Pharmacological stimulation Behavior

• Intrinsic factors: Genotype Stage of development Age Sex Location of injury Severity of injury Time post injury Prior experience

(Plowman & Kleim, 2010)


Use it or lose it Specificity Time Intensity

Use it and improve it Repetition Saliency Age Transference Interference

(Kleim & Jones, 2008)Property of Sheltering Arms. Do not use or alter without permission.

Studied the effect that constraint-induced movement therapy (CIMT) paired with rehabilitation has on rats s/p an intracerebral hemorrhage (ICH) Completed with 67 rats Divided into four study groups Behavioral training and recovery assessments

completed

(DeBow, Davies, Clarke, & Colbourne, 2003) Property of Sheltering Arms. Do not use or alter without permission.

Subjects that received a combination of CIMT and rehabilitation illustrated: Improved motor recovery Smaller volume of tissue loss

(DeBow, Davies, Clarke, & Colbourne, 2003) Property of Sheltering Arms. Do not use or alter without permission.

Study to determine the effect that skilled learning vs. strength training had on cortical reorganization Completed with 24 adult rats Divided into three study groups Movement analysis and electrophysiological

mapping completed to gather data


(Remple, Bruneau, VandenBerg, Goertzen, & Kliem, 2001)

“Power Reaching and Control Reaching animals exhibited a significant increase in the proportion of motor cortex occupied by distal forelimb movement representations (wrist/digit) and a decrease in the proportion of proximal representations (elbow/shoulder)” (Remple, Bruneau, VandenBerg, Goertzen, & Kliem, 2001, p. 133).


Study to examine the functional outcomes and neuromorphological changes that occur after receiving therapy 5, 14, and 30 days post stroke Conducted with 40 rats Five behavior assessments were completed Neuroanatomical procedures utilized to gather

data


(Biernaskie, Chernenko, & Corbett, 2004)

Rehabilitation 5 days post stroke had marked improvements on the behavioral assessments as well as improved an overall improvement of the number and length of dendritic branches

(Biernaskie, Chernenko, & Corbett, 2004) Property of Sheltering Arms. Do not use or alter without permission.

Studied the effect of highly repetitive skilled vs unskilled tasks on the overall learning process, synapse number, and brain function in the mammalian brain Completed with 12 rats Divided into two groups 400 repetitions of reaches each session


(Kleim, Barbay, et al., 2002)

Engagement in highly repetitive skilled reaching tasks: Produces more successful reaches overall Contribute to significantly more movement

representations within the caudal forelimb area (CFA) and significantly thicker cortices within the CFA

Increase number of synapses/neurons within the CFA

(Kleim, Barbay, et al., 2002)Property of Sheltering Arms. Do not use or alter without permission.

Two part study: 1- “To determine the effect of massed practice (MP)

verses massed practice combined with somatosensory stimulation (MP+SS) on cortical plasticity and function in persons with incomplete tetraplegia” (Beekhuizen & Field-Fote, 2005, p. 33).

2- Discover if greater improvement will occur in massed practice when combined with somatosensory stimulation Completed with 10 human subjects Divided into two groups Completed two hour sessions, five days/week, three weeks

total


This study indicated that it is possible to achieve additional functional gains even in the chronic stages of injury

Results indicated that subjects in MP+SS group demonstrated improvements in pinch, grip, and the Wolfe Motor Functional Test

Both groups demonstrated improvement in the Jebson Hand Function Test

(Beekhuizen & Field-Forte, 2005)Property of Sheltering Arms. Do not use or alter without permission.

Study on how many repetitions could be done in one hour and assess the benefit of highly repetitive training 13 human subjects diagnosed with chronic stroke Baseline assessments utilized Highly repetitive task-specific training

(Birkenmeier, Prager, & Lang, 2010)Property of Sheltering Arms. Do not use or alter without permission.

Results indicated it is feasible to achieve hundreds of task-specific upper extremity repetitions in one hour sessions Average of 322 repetitions per session

Improvement in outcomes noted

(Birkenmeier, Prager, & Lang, 2010)Property of Sheltering Arms. Do not use or alter without permission.

Researched the relationship between engagement in skilled motor tasks and the plasticity of the sensorimotor cortex Competed with 26 rats Included reaching and grasping training

Results indicated an increase in synapse strength was noted after continual stimulation for a prolonged period of time

(Monfils & Teskey, 2004)Property of Sheltering Arms. Do not use or alter without permission.

Study to investigate the possibility of delivering a highly repetitive, task-specific, individualized treatment training 15 human subjects Inpatient rehab setting Constraint induced movement therapy training

Results Average of 289 repetitions per session Forty-seven minutes of active training was achieved

per session Functional improvements noted

(Waddell, Birkenmeier, Moore, Hornby & Lang, 2014)Property of Sheltering Arms. Do not use or alter without permission.

Study to assess the effectiveness and use of the Hand Dance Pro gaming system with subjects s/p stroke greater than six months with hemiparesis 9 human subjects Outcome measures utilized Eight intervention sessions over a six week period

(Combs, Finley, et al., 2012)Property of Sheltering Arms. Do not use or alter without permission.

The use of this gaming system is feasible and resulted in improvement in UE movement in chronic stroke individuals

(Combs, Finley, et al., 2012)Property of Sheltering Arms. Do not use or alter without permission.

Study to determine if moving quickly has an effect on the performance of an impaired UE during a functional task 27 human subjects Outcome measure assessments utilized Trails completed for preferred speed Additional trails completed of same task at a fastest

possible speed


(Dejong, Schaefer, & Lang, 2011)

“People with mild to moderate post stroke hemiparesis are able to increase their movement speed on request, and when they do, movement quality is improved. Reach paths are straighter, finger movements are more efficient, and fingers open wider” (Dejong, Schaefer, & Lang, 2011, p. 368).

Improvement was shown for both groups


DOSAGE

INTENSITY

FREQUENCY

DURATION

VOLUME


A study in 2009 reported the average length of stay for a patient diagnosed with a CVA was 14 days in an inpatient rehabilitation setting

In addition, patients did not receive full “3 hours” of intensive therapy a day due to time spent setting up treatment, transportation, and medical needs

(Krakauer, Carmichael, Corbett, & Wittenberg, 2012)Property of Sheltering Arms. Do not use or alter without permission.

Additional studies indicated that task-specific training occurs in only about half of therapy sessions focused on the upper extremity

(Lang, Reisman, et al., 2009; Bernhardt, Chan, Nicola, & Collier, 2007; Harris, Eng, et al., 2009)


Robotics Arm Based Spring-Assisted Therapy Forearm Based Spring-Assisted TherapyHand Based Spring-Assisted Therapy Arm Based Functional Electrical StimulationHand Based Functional Electrical Stimulation Virtual Reality


REO-Go Armeo Power

http://www.motorika.com/?categoryId=65107http://www.hocoma.com/products/armeo/armeopower/


SaeboFlex

SaeboMAS

http://www.saebo.com/products/saeboflex/http://www.hocoma.com/products/armeo/armeospring/http://www.saebo.com/products/saebomas/

ArmeoSpring


Bioness H200RT300

http://www.bioness.com/H200_for_Hand_Paralysis.phphttp://www.restorative-therapies.com/products


Armeo Boom

http://itunes.apple.com/us/app/puzzle-me-!!!/id393499831?mt=8http://www.nintendo.com/games/detail/1OTtO06SP7M52gi5m8pD6CnahbW8CzxEhttp://www.mvrc.pitt.edu/facility_balance.htmlhttp://www.hocoma.com/products/armeo/armeoboom/features-functions/

iPad apps, e.g. Puzzle Me” Wii Sports Golf

Medical VR Center,

“Virtual Cave”


Benefits Evidence-based Concrete stimuli Specific to desired tasks Repetitive and intense Multi-sensory experience Modifiable Safe errors Interactive Provide feedback Provide objective data Capability to guide and

measure improvements

Limitations Cognitive requirement Visual component Contractures/Tone Pain if over-utilized Focus primarily on distal

recovery

Technological error Cost and accessibility Size of workspace



How is it implemented?

Utilizes advanced technology to better promote neuroplasticity principles High repetitions - High Intensity – Increased

Treatment Time Advanced technology can provide significantly more

repetitions than the therapist without getting tired! Task Specific Training Purposeful reaching/grasping/targeting facilitates better

results than rote exercise or training of isolated movements Goal oriented treatment gives patients a reason to move

Novelty – Cognitive Challenge Advanced technology treatment is more exciting and

stimulating than towel slides and passive range! Unilateral training– Multisensory treatment Increased awareness and focus on the affected extremity


REO

Bioness H200)

ARMEO Spring

SaeboFLEX

SaeboMAS

RT 300

Severe Impairment

Moderate Impairment

MildImpairment


Patient Information: Diagnosis: Right Pontomedullary ischemic CVA

8/6/14 54 Year old female Admitted to inpatient rehabilitation hospital on

August 8th, 2014 Social Environment: Married, Worked Full time

Past Medical History: Significant for high blood pressure, obesity

Prior Level Of Function: Independent with all self care, IADLs


Admission Functional Independence Measures

Eating- Supervision Transfers- Maximal Assist

Grooming- Minimal Assistance Toileting- Moderate Assist

Upper Body Dressing- Moderate Assist

Tub Transfers- Dependent(Did not occur due to safety)

Lower Body Dressing- Dependent Memory- Minimal Assist

Bathing- Maximal Assist Problem Solving- Minimal Assist

Toilet Transfers- Moderate Assist Social Interaction- Supervision


Admission Outcome Measures

Assessment Right Left

Grip 40 PSI 0 PSI

9 Hole Peg Test 47 Pegs 999 Pegs

Box and Block 42 Blocks 0 Blocks

Fugl Meyer 66 Points 9 Points


Plan of Care: Occupational Therapy focus on high repetitions

with the use of advanced technology Reo Bioness Armeo SAEBO MAS SAEBO Flex Weight bearing


Functional Independence Measures Admission FIMS Discharge FIMS

Eating Supervision Supervision

Grooming Minimal Assist Modified Independent

Upper Body Dressing Moderate Assist Modified Independent

Lower Body Dressing Dependent Supervision

Bathing Maximal Assist Modified Independent

Tub Transfers Dependent Modified Independent

Toilet Transfers Moderate Assist Modified Independent

Transfers Maximal Assist Modified Independent

Toileting Moderate Assist Modified Independent

Memory Minimal Assist Independent

Problem Solving Minimal Assist Independent

Social Interaction Supervision Independent


Outcome MeasuresAdmission Discharge

Assessment Right Left Right Left

Grip 40 PSI 0 PSI 66 PSI 15.6 PSI

9 Hole Peg Test 47 Sec 999 Sec 36.3 Sec 126 Sec

Box and Blocks 42 Blocks 0 Blocks 54 Blocks 26 Blocks

Fugl Meyer 66 Points 9 Points 66 Points 42 Points


Lack of repetition research in general Abundance of animal vs human research

Translating results of animal research Utilization of clinical judgment/inferences with

current research

Magic number of repetitions still unknown Lack of research with subjects who have fully

flaccid UEs Sheltering Arms current research project


Beekhuizen, K. S., & Field-Fote, E. C. (2005). Massed practice versus massed practice with stimulation: Effects on upper extremity function and cortical plasticity in individuals with incomplete cervical spinal cord injury. Neurorehabilitation and Neural Repair, 19, 33-45.

Bernhardt, J., Chan, J., Nicola, L., & Collier, J. M. (2007). Little therapy, little physical activity: Rehabilitation within the first 14 days of organized stroke unit care. Journal of Rehabilitation Medicine, 39, 43-48. http://dx.doi.org/10.2340/16501977-0013

Biernaskie, J., Chernenko, G., & Corbett, D. (2004, Feburary 4). Efficacy of rehabilitative experience declines with time after focal ischemic brain injury. Journal of Neuroscience, 24(5), 1245-1254.

Birkenmeier, R. L., Prager, E. M., & Lang, C. E. (2010, September). Translating animal doses of task-specific training to people with chronic stroke in 1-hour therapy sessions: A proof-of-concept study. Neurorehabilitation & Neural Repair, 24(7), 620-635. doi: 10.1177/1545968310361957

Combs, S. A., Finley, M. A., Henss, M., Himmler, S., Lapota, K., & Stillwell, D. (2012). Effects of a repetitive gaming intervention on upper extremity impairments and function in persons with chronic stroke: A preliminary study. Disability and Rehabilitation, 34(15), 1291-1298. doi: 10.3109/09638288.2011.641660

Debow, S. B., Davies, M. L.A., Clarke, H. L., & Colbourne, F. (2003, March 20). Constraint-induced movement therapy and rehabilitation exercises lesson motor deficits and volume of brain injury after striatal hemorrhagic stroke in rats. Journal of the American Heart Association, 34, 1021-1026. doi: 10.1161/01.STR.0000063374.89732.9F

DeJong, S. L., Schaefer, S. Y.,& Lang, C. E. (2011,December 2). Need for speed: Better movement quality during faster task performance after stroke. Neurorehabilitation & Neural Repair, 26(4), 362-373. doi: 10.1177/1545968311425926

Hension, J. W., & Keogh, B. P. (2010). Plasticity: Teaching the old brain new tricks. Neurology, 74, e53-e55. doi:10.1212/WNL.0b013e3181d7b472


Harris, J. E., Eng, J. J., Miller, W. C., & Dawson, A. S. (2009). A self-administered Graded Repetitive Arm Supplementary Program (GRASP) improves arm function during impatient stroke rehabilitation: A multi-site randomized controlled trial. Stroke, 40, 2123–2128. http://dx.doi.org/10.1161/STROKEAHA. 108.544585

Kleim, J. A., Barbay, S., Cooper, N. R., Hogg, T. M., Reidel, C. N., Remple, M. S., & Nudo, R. J. (2002). Motor learning-dependent synaptogenesis is localized to functionally reorganized motor cortex. Neurobiology of Learning and Memory, 7, 63-77. doi: 10.1006/nlme.2000.4004

Kleim, J. A., & Jones, T. A. (2008, February). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research, 51, S225-S239.

Krakauer, J. W., Carmichael, S. T., Corbett, D., & Wittenberg, G. F. (2012). Getting neurorehabilitation right: What can be learned from animal models? Neurorehabilitation and Neural Repair, 26(8), 923-931.

Lang, C. E., Macdonald, J. R., Reisman, D. S., Boyd, L., Jacobson, Kimberley, T., Schindler-Ivens, S. M., . . . Scheets, P. L. (2009). Observation of amounts of movement practice provided during stroke rehabilitation. Archives of Physical Medicine and Rehabilitation, 90, 1692-1698. http://dx.doi.org/10.1016/j.apmr.2009.04.005

Monfils, M. H., & Teskey, G. C. (2004). Skilled-learning-induced potentiation in rat sensorimotor cortex: A transient form of behavioural long-term potentiation. Neuroscience, 125, 329-336. doi: 10.1016/j.neuroscience.2004.01.048


Plowman, E. K., & Kleim, J. A. (2010). Motor cortex reorganization across the lifespan. Journal of Communication Disorders, 43, 286-294.

Remple, M. S., Bruneau, R. M., VandenBerg, P. M., Goertzen, C., & Kliem, J. A. (2001). Sensitivity of cortical movement representations to motor experience: Evidence that skilled learning but not strength training induces cortical reorganization. Behavioral Brain Research, 123, 133-141.

Waddell, K. J., Birkenmeier, R. L., Moore, J. L., Hornby, T. G., & Lang, C. E. (2014). Feasibility of high-repetition, task-specific training for individuals with upper-extremity paresis. American Journal of Occupational Therapy, 68(4), 444-453.


Presented by: Megan Setlock, MS, OTR/L; msetlock ... Million Dollar Question.pdfproportion of motor...

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