MS week 8.pdf

8.1 Neural Plasticity recovery: reaquisition of the normal movement patterns an individual had before an injury or disease neurons responsible for certain mvmt adapt by regenerating sprouts from adjacent neurons to recover lost • fxn ex; walking but w/hemiwalker compensation: fxn assumed by other...

8.1 Neural Plasticity recovery: reaquisition of the normal movement patterns an individual had before an injury or disease neurons responsible for certain mvmt adapt by regenerating sprouts from adjacent neurons to recover lost • fxn ex; walking but w/hemiwalker compensation: fxn assumed by other mechanisms compensatory techniques instead of recovery methods • ex: still asymmetrical loading a year post THR but can walk cortical remapping: experiences shape amount of neural acquisition to dif parts of brain • brain is plastic: shift & change based on activities learned/performed • ability to learn different motor patterns ex: reactive synaptogensis (cortical sprouting, by adjacent axons) post injury, move to cause plastic changes in response to stimuli & movement • develop to compensate for injury ex: immediately limp, extra cautious after healing subconscious collection of motor program -> builds motor plan -> hardwired like habit • can undo habits bc brain is plastic use-dependent cortical reorganization • refix bad habit plan of care after exam/eval recovery based or compensatory interventions • potential for recovery • cannot heal: compensatory ex: permanent nerve damage, comorbid diagnosis like peripheral neuropathy or dementia *also consider precautions & contraindications like surgery or life style factor caregiver support & living situation (SDOH) continue to reassess and connect w. other health care workers summary recovery: reaquistion of previous motor patterns compensation: adjustments/adaptions to previous motor patterns cortical remapping/plasticity: neural adjustments to changes in behavior or environment 8.2 Principles of Neuroplasticity 10 principles of Neuroplasticity govern the way we look at mvmnt acquisition • 1. Use it or Lose it the more neurons fire the more they strengthen • the less the fire the more they degrade ex: when you work out and eat right, you’ll show progress in muscle strength if you just sit around you will have muscle atrophy 2. Use it & improve it • muscle atrophy can be remedied by doing exercise • After repetitive training & rewards was an increase in digit representation w/ in cortex 3. Specificity • research suggested that neuroplasticity is specific particularly w skilled mvmnts or activities Means 2 things A. When a novel or new task is learned and practiced in a skilled manner, there’s an increase in cortical representation basically meaning, an increase in Neuroplasticity B. Mvmnt acquisition is heightened and motor mapping increased when activity performed is similar to activity that you’re tying to acquire 4. Repition Practicing something over and over again until activity is learned Constraint induced movement (CIMT) based upon recovery using principles of neuroplasticity 5. Intensity Encourage individuals to complete activities w intensity to maximize neural output ex: there is an overload principle associated with building muscle strength principle is rooted in the fact that increased stress to muscle or increased • intensity is needed in order for further muscle growth to take place one way we can increase stress to muscle or intensity is to increase training load can also increase # or reps & increases frequency of exercise • 6. Time Matters Maximize amount of experience-dependent plasticity, there is a time component variety of cellular interactions have to take place in order for body to • respond to an attempt to fix an injury ~it takes time~ Important- recognize that neuroplasticity take time voluntary exercise too early after injury to brain shows a decreased • expression of plasticity w/in the cortex 7. Saliency Where individuals learn more and have increased plasticity when skills or activities that are being done are meaningful to them • research suggests: this is due to the contribution or ACH and w an engagement of a task Saliency contributes to motivation and to learning new knowledge 8. Age Matters age becomes a factor over time when it comes to Neuroplasticity Those that are younger in age tend to have more robust cortical adaptations, with evidence showing decreased synaptogenesis and cortical map reorganization when we age. • normal aging process is associated with neuronal and synaptic atrophy 9. Transference ability for plasticity that occurs in one region to then carry over to another region - so if we build strength in our skeletal muscles during exercise, we also build cardiac muscle 10. Interference Can be seen as maladaptive response ex: daughter becoming dependent to using walker when she was learning how to walk Summary 10 Principles of Neural plasticity • Guides plan of care • Rooted in research • Applicable to all diagnoses 8.3 Practice Strategies to Improve Motor Fxn reference of correctness: body’s way of being able to recognize & respond to changing situations • allow pt to make mistakes & see what feels like to make a mistake ex: pt struggling to transfer, PT does not intervene and allows them to self correct can offer tip @ end to increase amount of learning (can ask pt how they feel and have them correct) practice w/ guided movement • • feel what a stereotypical natural movement feels like (if injury or disease in body) can be tactile, physical, verbal cues to talk through steps - can use tools in environment like mirrors ti help - if no guidance: frustration may increase, too much they may be reliant on us job as PT: teach pt effective strategies to take back with them to work independently as PTs help pt practice • enhances motor learning to modify life after injury, surgery, change in underlying process • results occur quickly then taper off • consider different types of practice distribution • amount of practice over period of time • rest and practice • most common • better for motor learning massed: provision of practice, amt of practice exceeds rest cons: can present fatigue & cause setbacks ex: help facilitate motor performance variability environment plays part in practice • degree that modifications are made w/in practice session • blocked (all trials of same task done at same time) good • can manipulate challenges for motor performance (don’t have to think hard) random • practice order • sequence in which practice is delivered • blocked: practice same skill over and over (not as much cognitive processing) but good for motor performance • random: same skill with modified contexts (environment or task variability) most motor learning here! • serial: only practice one thing for a while then move onto another (motor learning) mental practice: • similar activation of cortices compared to actual kinesthetic bc similar motor programs still used • good for pt who fatigues easily mental practice w/ physical performance • enhance retention per task - do in pieces to reach entire task ex: breaking down gait part to whole: maximize motor learning • continuous task summary: reference of correctness allows for motor learning/neuroplasticity, guided movement can be appropriate/inappropriate, characteristics of practical distribution, variability, order, environmental, type 8.4 Feedback Strategies to Improve Motor Fxn Augmented feedback another word for extrinsic feedback can be verbal, tactile, or using manual assistance using • biofeedback or auditory stimuli, or even w computerized devices ex of biofeedback: WII gaming system feedback & allows pt to provides pts knowledge of results—> meaning they are only • Also provide concurrent informed of results of activity - could tell us quality of mvmnt make changes in moment 9 types of feedback- extrinsically 1. Concurrent-constant -given during activity (like walking) Knowledge of results: “nice step” Knowledge of performance: “take a bigger step” 2. Terminal - mvmnt occurs and ends first before feedback given • All can be be given to promote learning to a degree and can utilize knowledge or results/ performance allows pt to make intrinsic adjustments during mvmnt and then receive extrinsic feedback w how to further adjust for next trial 3. Immediate - where feedback is given immediately after moment occurs 4. Delayed - pt may have more time to process and self reflect on where they went right and wrong 5. Summary -wait a few trials to see how pt self corrects • good option for pts farther along toward end of associative stage of learning- as they refine their processes for intrinsic self-reflection and response to error 6. Faded - pts are eased into removal of feedback; combo or immediate and summary feedback in same session • in beginning you give imm. Feedback slowly remove feedback after a couple trials • Allows for more motor learning: more cognitive processing and self assessment w corrections 7. Bandwidth opportunity for self assessment as feedback is given only when pt falls out of range or crosses a threshold 8. Blocked intrinsic cues are provided in same manner to same body segment each time and do not vary -ex: person dragging feet and provide verbal cue (feedback) 9. Random or variable provide feedback to various segments of body so information on knee and ankle and trunk ex: provide physical assistance to knee flexors as foot swings w each step Summary • Knowledge of Results o Feedback about the result of the movement • Knowledge of Performance o Feedback about the quality of the movement • Eight different types of feedback chosen based on: o Clinical decision making o Patient status o Stage of motor learning 8.5 Intervention strategies to improve motor fxn task oriented training • activity based (ICF) - gait, sit to stand, graspin • environment, feedback, & practice into consideration - push w/ appropriate amount in order to achieve intensity (monitor vitals and outcome measures like RPE) • recall principles of neural plasticity • limited benefits in individual cognitive deficits or limited active movement ability recognize environment challenges task oriented intervention • open/close • surface • sound • visual feedback etc behavioral shaping • how interventions consistently modified depending on pt • challenge/regress pt so don’t get frustrated or bored • use motivation & challenge task specificity (pt & PT agree) task specificity for mob training example: • integration of task oriented & specificity training use machine so pt can walk without using • training mechanisms arms and help w/ mobility - focused on limbs (UE/LE) - focused on mobility activities (gait/transfers/ body weight supported training) task analysis: helps understand movement deficits, underlying reasons for them ex: trouble lifting toes, look at ankle, gastric impairment specific interventions or interventions for body fxn/structure • strength training • flexibility ROM • neuromuscular reeducation • muscular endurance & fatigue • postural control and balance • coordination summary: task oriented training (acitivities) • • general activity training task specific training (activities/participation) task specific - training to specific goal activity - UE/LE - whole body • impairment specific training (body fxn/structure) 8.6 Impediments of Motor Control and Motor Learning Impairments resulting deficits from a path of physiological cause • caused directly from lesion or injury and are termed primary or direct impairments secondary impairments- result from original problem - take time to develop -contractures ~physio~ White blood cells and cytokines come into play w the inflammatory stage of healing are affecting injury Cardinal Signs Rubor, calor, tumor, dolor & weakness • primary impairments that occur as a direct result of a pathology -some ppl dont like to move after injury thus making cell mediators difficult to move If pt is not positioned correctly, muscles may become shortened and lead to a contracture, which is a permanent shortening of the muscles, tissues and tendons around the area. secondary/indirect result of knee surgery Muscle weakness inability to generate muscle force can stem from musculoskeletal system • or lesion to muscle or from neuromuscular systems- causing atrophy Weakness cause by CNS deficit would need to determine if lesion is either upper or lower motor neurons Upper Motor Neuron syem from cortex, brainstem and SC • clinical manifestation : increased tone, increased reflexes aka hyper reflexive • strength output in upper motor neuron injury is weakness, and that develops to either the CL or IPSI side of the body depending on where the lesion or the insult is in nervous system. Lower Motor Neuron injuries stem from CN’s: ant horns of the sc, spinal roots or peripheral nerves • display a decrease in tone and reflexes. • Weakness w LMN injuries is IPSI (same side as lesion) Abnormal muscle tone impediment to motor control/ motor learning & are deficets to neuromuscular system Hypertonia: abnormally high tone & associated disorder that contributes to hypertonia is spasticity Spasticity: exaggerated stretch reflex that is associated with an UMN lesion • lesion creates an imbalance of super spinal inhibitory & excitatory outputs to SC - key is velocity dependence Hypotonia normally low muscle tone Immediately after a CNS injury, patients • may develop acute flaccidity where there is a complete loss of muscle tone is imperative to protect the limb and • • joints in question to prevent subluxation and pts after knee surgery more than often like to be in loose consequent injury. packed position as the pain is alleviated Muscle contracture - they dont recognize that fixed resistance resulting from fibrosis of this is chronic and can set them tissues surrounding a jnt and restricting up for problems later on mvmnts Distonia sustained muscle contraction that often causes abnormal posturing ex: writers cramp Dyskinesia involuntary mvmnt that creates a riving mvmnt- aka apoptotic or coreafore qualities Ataxia disorder characterized by uncoordinated jerky mvmnts during voluntary mvmnt • pt w ataxia present w decreased strength and postural abnormalities Ambulating w ataxia severe loss of balance, wide BOS and Tremor pts would inhibit ability for controlled mvmnt • are associated w diagnosis or may be called- essential tremors inability to control mvmnts Peripheral nerve injuries Cerebral vascular accident or stroke can also constitute a lower motor neuron injury cause cognitive limitations as well as where there's decreased tone weakness, musculoskeletal deficits that decrease the decreased reflex signs availability for motor control and motor Ex: carpal tunnel Cerebral Palsy is another pathological condition that manifests from birth • considered non progressive, the effects from the movement patterns can lead to secondary musculoskeletal impairments such as decreased ROM, weakness, postural abnormalities learning. Summary Primary (Direct) vs Secondary (Indirect) Impairments Constraints to motor control/motor learning - Weakness/Contractures of Musculoskeletal origin - Weakness of Neuromuscular origin - Involuntary movement patterns - General diagnoses that may predispose deficits class notes 10/17 motor performance: in same session motor learning: long term why get to pt early: bc can get back to baseline quicker but too early is a thing see like a week after? just depends on severity Blocked & Massed