Maximizing Functional Recovery Across the …...Maximizing Functional Recovery Across the Continuum...

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Acute & Chronic Stroke

Mike Studer, PT, MHS, NCS, CEEAA, CWT, CSST

Maximizing Functional Recovery Across the Continuum


• Financial– None

• Non-financial– None

Disclosures


• 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


Chapter One

The Physiology of Stroke in Rehabilitation


• 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


• Finished• Cannot change

• Done

• Sorry• One year

• We tried • Six months

• Nothing more we can do

Chronic Stroke: Time Frame?


• 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


• 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


• Successful novel experiences• New connections

• Improved use of neurotransmitters

• Frequently used, efficient pathways• Improved blood flow

Neuroplasticity: Learning Bases; Structural and Chemical


How Does the Brain Reorganize?

• Physiologically– Synaptogenesis– Angiogenesis– Dendritic arborization– Synaptic efficacy– Collateral sprouting

• Functionally– Habituation– Adaptation– Compensation

(substitution)


• 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


• 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


• 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


“Why”: Stimuli to Induce Neuroplasticity


• 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?


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


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


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.)


• 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


• 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


• 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


• 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


• 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


Chapter Two

Where Can They Improve? Seven Domains of Potential for Your Patient


• Neuroplasticity: motor• Neuroplasticity: sensory

• Muscular strength

• Muscular endurance• Cardiovascular endurance

• Psychological • Cognitive

Resources in Stroke Rehabilitation


• 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


• 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


Forcing the brain to recognize AND need the UE:

• Opportunistic

• Use

• Therapy

Somatosensory Reweighting UE: OUT


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)


• Muscular strength• Muscular endurance

• Cardiovascular endurance

• Psychological• Cognitive

Fitness (Physical and Mental) Training: Capacity


• 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


Muscular Strength (cont.)


• 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


Muscular Endurance (cont.)•


• 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


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


• 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


• 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


• 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


• 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


• How does fitness reduce disability?• How does fitness prevent disability?

• How does fitness influence neuroplasticity (two)?

The Fitness Cycle


Fitness

Neuroplasticity

Functional integration

Preventing disuse loss

Preventing accidental loss Fitness


• 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


• 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


• Read personalities• Integrate patient preferences

• ICF: roles and responsibilities

• OPTIMAL theory of motor learning– Autonomy– Enhanced expectancies– External focus

Psychological: Personalized and Attentive


• Stimulate awareness: for accuracy in judgment • Reaction speeds

• Judgment/inhibition

• Dual-task capacities

Cognitive: Reserve, Speed, and Safety


Chapter Three

Evidence-Based Stroke Rehabilitation: Acute and Chronic Recovery Principles


• Optimizing• Performance

• Through

• Intrinsic• Motivation

• Attention• Learning

Lewthwaite, Wulf – 2016

OPTIMAL


• 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


• “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


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


• 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


Autonomy and Enhanced Expectancies:

In Action!


• Neurotransmitter and neuromodulators– Dopamine– Serotonin– Endorphins

• Growth factors– BDNF/IGF/GDNF

• Reduces cortisol

Neurophysiologic Benefits of Autonomous Support


• 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”


Espy, D: Used with personal permission

Perceived Exertion Drives Dosage: “Autonomy Meets the Borg Scale” (cont.)


• 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


• 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


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


• Patient choice without burden• Patient involvement without being patronizing

• Teamwork, not hierarchy

• Facilitating choice within reality and personality

Supporting Autonomy (AS)


• Principles of motor learning apply (KR/KP)• Consider the stage of learning for each person

• Focusing on– External– Environmental– Movement effects

Focusing Externally (EF)


• Reinforcing vicarious experiences: PT and patient• Recalling recent gains prior to the next trial

• Affirming language

• Dyad training• Videotape support

Enhanced Expectancies (EE)


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)


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)


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)


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)


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)


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)


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)


Chapter Four

Motivational and Exercise Attributes After Stroke


• Depression and mood• Self-efficacy

• Optimism/pessimism and personality

• Apathy• Task specificity and salience

• Balance of success and challenge

Motivation: Critical Variables


• Autonomy• Mastery

• Productivity

• Dopamine if surprising/stimulating/successful• Serotonin if wellness for self

• Oxytocin if wellness for others

Self-Efficacy


• Attention• Personalization

• Gamification

Motivational Considerations


Attention– Test– Measurement– Prediction– Reporter

Motivational Considerations (cont.)


Personalization– Priming– Salience/specificity/autonomy– Enhanced expectancies



• 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


Gamification– Measurements– Patients informed of scores, upcoming tests– “High-score fever”



• 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


• Attention• Motivation

• Intensity

• Automaticity

The Essential Concepts to Apply


How Is Your Current Engagement Approach Working? Fear and Threats


• Personality• Self-efficacy

• Motivation

• History (work, ACEs, etc.)• Interests

• Past rehabilitative experiences

Subjective Examination


• 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


• Competitive• Depressive

• Instructive (awareness)

• Shaming• Burdensome

• Motivational• Frustrating

• Shaping

The Individualized Role of Errors


• SIRROWS stroke study• Yesterday, your walking speed was

• Today, your walking speed is

PROVE Outcome Expectations: What Did You Accomplish?


• Modified SIRROWS stroke study• Yesterday, your walking speed was

• Today, predict your walking speed

PROVE Outcome Expectations: What Did You Accomplish? (cont.)


Capture attention through– Interest/salience– Test

– Challenge– Patient predictions– Patient reporting– Autonomy

– Goal-direction– Measurement/gamification– Error estimation

– Dyad training

Maximize Outcome With Intensity


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


• Consider patient personality• Confidence

• Self-efficacy

• Patients may be competing against themselves, you, another patient, or an issued “challenge”

Intensity = Challenge = Interest


• 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


• 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.)


Break


Chapter Five

Practice Structure and Feedback Attributes After Stroke


• 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


• Specificity• Frequency

• Redundancy

• Feedback• Evolutions with learning

• Success vs. boredom: challenge point hypothesis• Error-induced training

• Automaticity and dual-task loading

Practice Variables


• 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


• 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


• 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”


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


Error Dosage in Mobility


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


Error Dosage in ADLs


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


• 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


Where Are Procedural Memories Processed Before Stroke?

Procedural memories with attentional supervision to task and environmental constraints

– Swallowing– Speaking– Walking– Dressing – Hygiene


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


Where Is Swallowing ProcessedBefore Stroke?

The swallow experiment, Part 1


Where Do These Tasks Reemerge After Traditional Stroke Rehab? (Cues, Attention Based)

The swallow experiment, Part 2

Robertson, 2009


• 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


How Is Dual-Task Tolerance Improved?


• 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


Attentional and Procedural Networks


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


• 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


• 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


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.)


Retraining Automaticity – not limited to gait OR treadmill!


Automaticity in Walking


Automaticity in ADLs


Automaticity in Conversation


Automaticity in Avocation


Automaticity in Swallow


• 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?


• 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.)


• Optimizing• Performance• Through• Intrinsic• Motivation• Attention for • Learning

• Autonomy• Enhanced expectancies

• External focus

Resource: OPTIMAL Theory of Motor Learning


• 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


Overcoming disbelief, “I am done improving”– Measuring change– Motivating from within– The dosage of intensity

Case Studies: Chronic Stroke


• Incentives• Constraints

• Rewards

Neuroplastic Stimuli Reiterated


Chapter Six

Introduction to Advanced Concepts


• 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


Opportunistic Use Therapy


• 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?


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


• Personalization• Functional specificity

• Challenge

• Test• Prediction

• Reporter• Gamification

• Vicarious experiences

Methods to Maximize Attention


• Measurement is critical• How do I measure the frail patient?

• Frail patient considerations

The Frail and Very Elderly Stroke Patient


• 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


• 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


Chapter Seven

Summary


• 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


• 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


• 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


• 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


• Greater motivation often leads to improved neuroplastic stimulus through intensity, attention, and (after successful trial) dopaminergic rewards

• Motivation can dysfunctionally lead to addiction

Motivation


• 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


• 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


• 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


• 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


• [email protected]• YouTube

– Rehabilitation NWRA

• www.mikestuder.com• Facebook

– NWRehab

Mike Studer, PT, MHS, NCS, CEEAA, CWT, CSST


Break


Question and Answer Session

Maximizing Functional Recovery Across the Continuum: Acute & Chronic Stroke

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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.

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