Dead sea 2012 gordon final

IPRCIPRC

Andrew M. Gordon, Ph.D.

Overview of my research

Systems Systems neuroscience, neuroscience, motor learning & motor learning &

controlcontrol

Neural Neural

mechanisms mechanisms

underlying underlying

movementmovement

disordersdisorders

Development and Development and

testing of rehabilitation testing of rehabilitation

protocolsprotocols

•Neural basis of movement Neural basis of movement representationsrepresentations•Sensorimotor Sensorimotor transformation underlying transformation underlying UE movementUE movement

•Sensory motor controlSensory motor control•Motor planningMotor planning•Digit individuationDigit individuation•LearningLearning

•Evidence-based practiceEvidence-based practice•Role of treatment intensityRole of treatment intensity•Dosing & ingredientsDosing & ingredients•Treatment specificityTreatment specificity•Neural correlates of rehabNeural correlates of rehab

• The hand is fundamental to The hand is fundamental to

sensorimotor development sensorimotor development

• The unique versatility of the The unique versatility of the

hand hand motormotor system enables system enables

highly dexterous control of a highly dexterous control of a

large repertoire of movementslarge repertoire of movements

• The The sensory sensory machinery of the machinery of the

hand allows to extract detailed hand allows to extract detailed

knowledge about objects we knowledge about objects we interact with interact with

The human hand: Basic science and clinical applicationsThe human hand: Basic science and clinical applications

Symptoms Include:

Abnormal muscle tone

Posturing into wrist flexion, ulnar deviation, elbow flexion and shoulder rotation

Reduced strength

Tactile and proprioceptive disturbances

Developmental non-use

Impaired motor planning

Impaired motor learning

Impaired Hand Function in Hemiplegic CPImpaired Hand Function in Hemiplegic CP

Corticospinal (CST) tract integrity is predictive of hand function

Bleyenheuft et al. 2007Bleyenheuft et al. 2007

Timing of CNS damage and CST innervation pattern affect dexterity

Staudt et al. (2004)Staudt et al. (2004) Holmstrom et al. (2010)Holmstrom et al. (2010)

•Sensory impairments

•Impaired movement execution.

Hand function in hemiplegic CP

Impaired digit individuation

Petra & Gordon (In Preparation)

3 secs

II=.90

II=.88

II=.80

II=.86

II=.96

II=.69

II=.47

II=.58

II=.23

II=.22

Impaired digit individuation

Petra & Gordon, In Preparation

where IIj is the individuation index of the instructed jth digit while Nij is the normalized displacement of the ith digit during the jth instructed movement and n is the number of digits (n=5).

where SIi is the stationarity index for a non-instructed digit Nij is the normalized 3D resultant displacement of the ith digit during the jth instructed movements and m is the number of instructed movements (m=5).

Impaired precision grip

Eliasson et al. (1991)Eliasson et al. (1991)

•Impaired movement execution.

•Impaired anticipatory control (Eliasson et al. 1992; Gordon & Duff 1999).

- 400 gm--- 200 gm

Gordon & Duff (1999a)Gordon & Duff (1999a)

Impaired anticipatory fingertip force coupling during gait

Prabhu et al. (2011)Prabhu et al. (2011)

Visuomotor efficiency (VME) index

• Step 1

Discriminant analysis to determine if the hand postures are reliably different from one another – (linear combination of joint angles)

• Step 2

Values of each discriminant function are used to construct a confusion matrix (Information Theory) that summarizes the extent to which hand posture predicts shape.

• Step 3

Entries from the confusion matrix are further analyzed and a ratio is computed (VME index)

Raghavan, Santello, Gordon & Krakauer 201Raghavan, Santello, Gordon & Krakauer 2010)0)

Summarizes information about the extent to which hand posture discriminates towards object. Summarizes information about the extent to which hand posture discriminates towards object. Computed using all measured joints of each digit at 5% intervals during reach-to-grasp.Computed using all measured joints of each digit at 5% intervals during reach-to-grasp.

Wolff, Raghavan & Gordon (In preparation)Wolff, Raghavan & Gordon (In preparation)

Reduced discrimination across objects

Wolff, Raghavan & Gordon (In preparation)Wolff, Raghavan & Gordon (In preparation)

•Impaired movement execution

•Improves during development (Eliasson et al. 2006; Fedrizzi et al. 2003; Holmefur, et al. 2010).

Development of hand function a 13 year perspective

Jebson Hand function test

hemi1 hemi 2 hemi 3 hemi4 hemi5 diplegia 1 diplegia 2 diplegia 3 diplegia 5mean typical dev

6-8 years 19-21 years0

NACENT1965CENT1965NA KAPSYL

Eliasson, Forssberg, Hung, Gordon. (2006) Pediatrics

Experimental dataTemporal pattern

Time to lift offfinger differences, preload and loading phase

hemi 1 hemi 2 hemi 3 hemi 4 hemi 5 diplegia 1 diplegia 2 diplegia 3 diplegia 4 diplegia 5 mean typical dev

6-8 years 19-21 years0,2

Position

Load force

Grip forceGripforce

6 year 19 year Typical dev, adult

Eliasson et al 2006Eliasson et al 2006

Eliasson, Forssberg, Hung, Gordon. (2006) Pediatrics

•Improves with intensive practice (Gordon & Duff, 1999; Duff & Gordon 2003).

- 400 gm--- 200 gm

Gordon & Duff (1999a)Gordon & Duff (1999a)

Digit individuation improves after training

Individuation Index for the CIM T Group Ave rage Perform ance

thumb index middle ring little

before CIMT

af ter CIMT

Petra & Gordon (In preparation)Petra & Gordon (In preparation)

Thus, impaired hand function is not static

•Both upper extremities affected.

(Gordon & Duff 1999b)

The “less-affected” hand is also affected!

•Impaired bimanual coordination.

Impaired bimanual control

DrawerDrawer

SwitchSwitch

HandleHandle

Reflective markerReflective marker

HHuunngg eett aall.. 22000044,, 22001100

Impaired bimanual control

Islam et al. (2011)

•Impaired bimanual coordination.

•Role of less-affected hand in rehabilitation?

(Gordon, Charles & Steenbergen 2006)

Proprioceptive and tactile information can be transferred between hands!

Simultaneous grasping with both hands may improve grasp force control in more affected hand,

but potentially at the cost of time.

Steenbergen, Charles & Gordon (2008)Steenbergen, Charles & Gordon (2008)

Motor Learning

• Motor learning is “a set of processes involving practice and exercise leading to a relatively stable change in motor behaviour” (Schmidt 1988)

• Skill is "the ability to consistently attain a goal with some economy of effort" (Gentile 1987).

• Skill is achievement of the goal rather than the movement form.

Ann Gentile

What do we know about motor learning in CP?

What do we know about motor learning in CP

• We know relatively little

• Performance improves with practice (e.g., Neilson et al. 1990, Valvano & Newell 1998, Gordon & Duff 1999, Shumway-Cook et al. 2003)

• Need more practice than TDC

ConclusionsConclusions

• Performance improves with practice (e.g., Neilson et al. 1990, Valvano & Newell 1998, Gordon & Duff 1999)

• Need more practice than TDC.

• Blocked vs. random may not matter (Duff & Gordon 2003)

• Blocked vs. random

• Unlike adults, TDC may benefit from feedback, slower withdrawal, esp. for difficult tasks, (Sullivan et al. 2008, Goh et al. 2012, Sidaway et al. 2012, cf. Hemayattalab and Rostami 2009).

• Blocked vs. random

• Feedback frequency

• Task versus movement

van der Weel et al. (1991)van der Weel et al. (1991)

Movement quality is higher when practiced in the context of activities

What do we know …• Robotic assistive technology: only a select set of movements

needed to promote generalization.” (Krebs et al. 2012)• Control strategy is not based on robust knowledge of the dynamical

features of their upper limb (Masia et al. 2011)• Attentional/executive impairments (Bottcher et al 2009) • Sequence learning impairments (Gagliardi et al. 2011)• Learning styles may be important (Smits et al 2011)• Some children may benefit from teaching cognitive strategies

(Thorpe & Valvano 2002)• Most of what we know is from laboratory tasks

Conclusions

Motor system physiology is highly variable among individuals with CP, but the impairment patterns (movement execution, planning and learning) are remarkably consistent.

Connect clinical and basic research.

Understanding mechanisms of impairment and recovery essential to drive the field.

AcknowledgementsAcknowledgements

Clinical studies: Marina Brandao, OT, PhD, Ya-Ching Hung, PT, EdD, Cherie Kuo, PT, Claudio Ferre, MS, Ashley Marina Brandao, OT, PhD, Ya-Ching Hung, PT, EdD, Cherie Kuo, PT, Claudio Ferre, MS, Ashley Chinnan, PT, Jeanne Charles, PT, MSW, PhD, Bert Steenbergen, Eugene Rameckers, PT, PhD, Yannick Bleyenheuft, PT, Chinnan, PT, Jeanne Charles, PT, MSW, PhD, Bert Steenbergen, Eugene Rameckers, PT, PhD, Yannick Bleyenheuft, PT,

PhDPhD

TMS/Imaging: Kathleen Friel, PhD, Kathleen Friel, PhD, Sarah Lisanby, M.D., Jason Carmel, M.D. Arielle Stanford, M.D., Stefan Rowny, M.D., Joshua Berman, M.D. Charles Schroeder, Ph.D., Bruce Bassi, David Murphy, Jaimie Gowatsky, Joy Hirsch, Ph.D.,

Stephen Dashnaw, Glenn Castillo

Volunteers Volunteers

ParticipantsParticipants Supported by:Supported by:

http://www.facebook.com/CenterCPResearchThrasher Research FundThrasher Research Fund

CVS CaremarkCVS CaremarkE-mail: ag275@columbia.eduE-mail: ag275@columbia.edu

MOTOR LEARNING BASED MOTOR LEARNING BASED TREATMENT TREATMENT

APPROACHES FOR UPPER APPROACHES FOR UPPER EXTREMITYEXTREMITY

REHABILITATION IN REHABILITATION IN CHILDREN WITH CHILDREN WITH

HEMIPLEGIAHEMIPLEGIA Andrew M. Gordon, Ph.D.Andrew M. Gordon, Ph.D.

Overview

• Motor learning in CP

• Motor learning approach to physical rehabilitation

• Intensity of training

• Specificity of training

• How to achieve intensity

• Skill training and plasticity

• Where to from here?

Motor learning based approaches to rehabilitation

• Janet Carr and Roberta Shepherd • Rehabilitation involves motor learning• Pediatric therapists are increasingly aware of infants and children

as active participants rather than as passive recipients of therapy.

Ann Gentile

• “Don’t mislead them by telling them a form that you think will work.”

• “Establish the goal, set up the regulatory stimulus conditions…”

• “The behaviour that dominates our daily lives is directed toward the accomplishment of goals. It is aimed at a specific purpose or end that we are trying to achieve”(Gentile 2000, p112).

• Problem solving!!!

Pediatr Phys Ther 2001;13:68–76

Reviews

• More than 70 studies of peds CIMT, 26 RCT

Reviews:

• Sakzewski et al. (2009) Pediatrics. 123(6):e1111-22.

• Gordon (2011) Dev Med Child Neurol.• Gordon, AM Constraint-induced therapy and bimanual training in children with

unilateral cerebral palsy. In: R Shepherd (Ed.) Cerebral Palsy in Infancy and Early Childhood Optimizing Growth, Development and Motor Performance. Elsevier. (In Press).

CIMT studies CIMT studies in CPin CP

Data plotted from Charles et al. 2006; Gordon et al. Data plotted from Charles et al. 2006; Gordon et al. 2006; Gordon et al. 2007; Gordon et al. 20112006; Gordon et al. 2007; Gordon et al. 2011

Dosing

90 hrs CIMT (n=21)90 hrs CIMT (n=21)

60 hrs CIMT (n=31)60 hrs CIMT (n=31)

Pre-testPre-test Post-testPost-test

Gordon 2011) DMCNGordon 2011) DMCN

First p re te st First TxPo st-te st

O ne ye a rPo st-te st

Se c o nd TxPo st-te st

First TxSe c o nd Tx

So CIMT is not a one-time miracle.

Charles and Gordon (2007) DMCN

Intensity of practice matters

Motor System NNeurophysiology in ChildrenChildren with Hemiplegic CP

IIpsilateral connectivity of impaired hand may bemay be maladaptive, that children with this organization pattern have more severe deficits and are less responsive to therapies (Kuhnke et al. 2008).

Kuhnke et al.( 2008)

International consensus meeting on pediatric CIMT, January 2012, Stockholm, Sweden

And the consensus on what we know was……

• It works!

• It works in young and older children

• It works when given 24/7 or just 2 hrs/day

• It works with casts, slings, gloves, and no restraint whatsoever

• Repeated bouts work

• A lot of something is better than little or nothing of something else.

• No evidence that any specific model of CIMT demonstrates greater improvement than another.

• No new knowledge being generated as the same thing tends to be done over and over across studies.

Hand-Arm Bimanual Intensive Therapy (HABIT)

HABITHABIT• No restraintNo restraint• Same duration as CIMTSame duration as CIMT• Bimanual activities (e.g., cards, Bimanual activities (e.g., cards,

wrapping presents, video games, ball wrapping presents, video games, ball throwing, zipping a jacket)throwing, zipping a jacket)

Task DesignationTask Designation• StabilizerStabilizer• Passive/active assistPassive/active assist• ManipulatorManipulator

• Gordon et al. (2007, 2008, 2011Gordon et al. (2007, 2008, 2011))

Charles and Gordon, (2006) Dev Med Child Charles and Gordon, (2006) Dev Med Child Neurol Nov;48(11):931-6. Neurol Nov;48(11):931-6.

HABIT Results

Controls

Pretes t Imm ediate post -test

One m onthpost-test

Assistin g Hand Asses sment

Pretest Immedia te post-tes t

One monthpost-tes t

TX InvolvedControl Involved

TX Non-InvolvedControl Non-Involved

Acc elerometry

Gordon et al. Dev Med Child Neurol. 2008)Gordon et al. Dev Med Child Neurol. 2008)

Data plotted from Gordon et al. 2007; Gordon et al. 2011Data plotted from Gordon et al. 2007; Gordon et al. 2011

Dosing

90 hrs HABIT(n=21)90 hrs HABIT(n=21)

60 hrs HABIT(n=10)60 hrs HABIT(n=10)

Pre-testPre-test ImmediateImmediate

Post-testPost-test

1 month1 month

Post-testPost-test

6 month6 month

Post-testPost-test

Gordon (2011) DMCNGordon (2011) DMCN

Specificity of practice

Best learning is hypothesized to occur when practice characteristics are the same as those of the test (Thorndike 1914, Shea & Wright 1995)

Randomized trial comparing CIMT and bimanual training (HABIT) that

maintains the intensity of practice associated with CIMT

Hypothesis: participants in the CIMT group will have greater improvements in unimanual dexterity whereas participants in the bimanual training group will have greater improvements in bimanual hand use—i.e., specificity of training.

Gordon et al. (2011), Neurorehab & Neural Repair)Gordon et al. (2011), Neurorehab & Neural Repair)

No specificity of training

HABITHABITCIMTCIMT

Effects on Structural Integrity of Motor System on recovery

RR22=.70=.70

• Hypothesis: participants in the CIMT group will Hypothesis: participants in the CIMT group will have greater improvements in unimanual dexterity have greater improvements in unimanual dexterity whereas participants in the bimanual training whereas participants in the bimanual training group will have greater improvements in bimanual group will have greater improvements in bimanual hand use—i.e., hand use—i.e., specificity of trainingspecificity of training. .

Brandao, Gordon & Mancini, AJOT (2012)Brandao, Gordon & Mancini, AJOT (2012)

Specificity of training

Hung et al. (2011)Hung et al. (2011)

DrawerDrawer

SwitchSwitch

HandleHandle

Reflective markerReflective marker

Normalized Movement Overlap

pre post

involved HABIT

non-invovled HABIT

Involved CIT

non-invovled CIT

Movement overlap of the two Movement overlap of the two hands increases after hands increases after

bimanual trainingbimanual training

TreatmentsTreatments

Hung et al. (In Preparation)Hung et al. (In Preparation)

Specificity of trainingTrunk contribution to Trunk contribution to

unimanual reaching decreases unimanual reaching decreases after CIMTafter CIMT

Combined CIMT/Bimanual training (AHA)

Pre-testPre-test Post-testPost-test 8 wks8 wks

Aarts et al. 2010Aarts et al. 2010

Combined CIMT/Bimanual training

Cohen-Holzer et al. 2011Cohen-Holzer et al. 2011

Individual or combined CIMT & HABIT

CIMT 60 hrs (n=20)

HABIT 60 hrs (n=10)

CIMT/HABIT Hybrid30/30 hrs (n=4)

P r e t e st I m m e d ia t e

p o s t te s t

1 m o n t h

p o st te s t

6 m o n t h

p o st te s t

ylor t

Gordon (2011) DMCNGordon (2011) DMCN

Magic HABITMagic HABIT

Green, Shertz, Gordon, Moore, Schejter Margalit, Farquharson, Ben Bashat, Weinstein, Lin, Fattal-Valevski Green, Shertz, Gordon, Moore, Schejter Margalit, Farquharson, Ben Bashat, Weinstein, Lin, Fattal-Valevski (Submitted)(Submitted)

Summary•Both CIMT and bimanual training improve unimanual and bimanual function similarly in children with hemiplegia (see also recent studies by Sakzewski, Wallen, Facchin, Hoare and forthcoming studies by Deppe).

•Bimanual training may improve coordination of the two hands to a greater extent and allow practice of functionally meaningful goals, whereas unimanual training may improve unimanual control.

•Not mutually exclusive of each other, and can perhaps be combined over time as seen fit.

Hand-Arm Bilateral Intensive Therapy Involving Lower Extremities (HABITILE)

• Examined the efficacy of a novel intensive intervention including systematically training upper and lower extremities (LE) in children with hemiplegic CP

• 12 children 6-13 years of age in sleep-over camp in Brussels

• 90 hours training

• LE training included seating children on fitness balls or having them stand on balance boards during manual activities, gross motor activities, strength training, and use of a climbing wall

Bleyenheuft et al. (In Preparation)Bleyenheuft et al. (In Preparation)

HABITILE: Results

T0 T1 T2 T3

P=0.005

Bleyenheuft et al. (In Preparation)Bleyenheuft et al. (In Preparation)

Pre-tests Post-tests

T0 T1 T2 T3

logits)

P<0.001P<0.001

Pre-tests Post-testT0 T1 T2 T3

P<0.001P<0.001

Simona Bar-Haim et al (2010) Effectiveness of motor learning coaching in children with cerebral palsy: a randomized controlled trial. Clin Rehab 24: 1009-1020

• Evaluated effectiveness of motor learning on retention and transfer of gross motor function in children with CP.

• 78 children with spastic cerebral palsy, gross motor functional levels II and III, aged 66 to 146 months.

• 1 hr/day, 3 days/week for 3 months treatment with motor learning coaching or neurodevelopmental treatment:

Plotted from, Bar-Haim et al. 2010Plotted from, Bar-Haim et al. 2010

PretestPretest Post-testPost-test 3 mos3 mos 9 mos9 mos

NDTNDT

MLCMLC

Improvements in GMFM-66 retained after motor learning coaching

Does it matter who provides training and where?

Preschool environment--No specificity of training

Gelkop, D. Goal, Lahav, Brezner, Oribi, Ferre, Gordon (In Preparation)In Preparation)

Rethink usual and customary Rethink usual and customary care school schedule?care school schedule?

Does it matter whether PTs/OTs provide the training?

JTTHF Change Score by Interventionist Type

nds PT/OT

Non-PT/OT

AHA Change Score by Interventionist Type

Non-PT/OT

Plotted from Gordon et al. 2011Plotted from Gordon et al. 2011

Home CIMT by therapists

Al-Oraibi & Eliasson et al. 2011Al-Oraibi & Eliasson et al. 2011

Feasibility of a Home-based Hand-arm Bimanual Intensive Training for Young Children with Hemiplegic Cerebral Palsy

Ferre et al. In PreparationFerre et al. In Preparation

Poster session 2, #156Poster session 2, #156

9 weeks9 weeks

Children with hemiplegic Children with hemiplegic CP (n=7) age 1.5 to 4 yearsCP (n=7) age 1.5 to 4 years

Caregivers administer HABIT under supervision of a Caregivers administer HABIT under supervision of a trained interventionist 2hrs/day, 5x/weektrained interventionist 2hrs/day, 5x/week

Preliminary Results: Bimanual hand use

Summary•Benefits of intensive motor learning based therapies not limited to upper extremities.

•CIMT/Bimanual therapy can be administered in camps, schools and home by therapists, trained students or caregivers.

Skill training

• Newly learned movements are represented over large cortical areas (e.g., Kleim et al. 1998, Plautz et al. 2000)

• "repetitive motor activity alone does not produce functional reorganization of cortical motor maps… Instead, motor skill acquisition, or motor learning, is a prerequisite factor in driving representational plasticity in motor cortex” (Nudo 2003).

Feline model of forced use and skill training

• Restrain unaffected forelimb (jacket with one sleeve tethered to chest), forced use of affected limb– 23 hrs per day– Either restraint alone or paired with daily reach

training (1 hr per day)

• Restraint +/- training from 8-13 weeks of age, “early training”, immediately following the period of M1 inactivation

Friel Ket al. Neurosci. 2012; 32: 9265-76.Friel Ket al. Neurosci. 2012; 32: 9265-76.

Early training improves ladder Early training improves ladder stepping accuracy to normal levelsstepping accuracy to normal levels

Friel K, Chakrabarty S, Kuo HC, Martin J. J Neurosci. Friel K, Chakrabarty S, Kuo HC, Martin J. J Neurosci. 2012; 32: 9265-76.2012; 32: 9265-76.

Early Training Results in Upregulaltion Early Training Results in Upregulaltion of Choline Acetyltransferrase (ChAT)of Choline Acetyltransferrase (ChAT)

In cat model, hemiplegia without rehabilitation decreases In cat model, hemiplegia without rehabilitation decreases cholinergic function in spinal cord interneurons (Chakrabarty et cholinergic function in spinal cord interneurons (Chakrabarty et al. 2009).al. 2009).

Early training - large amounts of ChAT on affected side. Early training - large amounts of ChAT on affected side. No increases in ChAT on the affected side, compared to the No increases in ChAT on the affected side, compared to the

unaffected side, after restraint alone.unaffected side, after restraint alone.

Friel K, Chakrabarty S, Kuo HC, Friel K, Chakrabarty S, Kuo HC, Martin J. J Neurosci. 2012; 32: 9265-Martin J. J Neurosci. 2012; 32: 9265-76.76.

Does structured practice matter?

• RCT of 24 children, age 6-14yrs

• Structured practice group: Environmental constraints manipulated, skill progression, part-practice (shaping), goal-directed.

• Unstructured practice group: Bimanual play

• Day-camp environment, 6 hrs/day, 15 days

• AHA, Jebsen-Taylor, Abilhand-Kids, COPM

• Testing immediately before and after tx, 6-months

• Evaluator and interventionists blinded

Brandao et al. In PreparationBrandao et al. In Preparation

Hypothesis: participants in the structured skill practice group will have greater

improvements than participants unstructured practice group

Similar improvements regardless of practice type

Brandao et al. In PreparationBrandao et al. In Preparation

Hypothesis: participants in the structured skill Hypothesis: participants in the structured skill practice group will have greater practice group will have greater

improvements than participants unstructured improvements than participants unstructured practice grouppractice group

• Single-pulse TMS mapping, Magstim 200 stimulator, figure-8 coil.

• Co-registered TMS stimulation sites to individual MRIs, Brainsight software.

• Recorded EMG in digit, wrist, and biceps muscles bilaterally during TMS.

• Mapped hand representation bilaterally, 1 cm intervals, centered around spot of greatest activation of digit muscle.

• Mapping intensity – 110% pre-training motor threshold.

• Same TMS intensity used before and after training.

Cortical representations

Friel et al. In PreparationFriel et al. In Preparation

Intensive bimanual training improves hand function irrespective of CST pattern

**** ****

N=7N=7

N=4N=4

N=2N=2

TMS Map – Affected Hand, TMS Map – Affected Hand,

Structured Skill TrainingStructured Skill Training

Expansion and Strengthening of Ipsilateral Map of Impaired Digit

Friel et al. In Friel et al. In PreparationPreparation

• Hand Map expands for structured practice group

• But not for unstructured practice group

• Motor Learning!!!

Summary

• At least at such high training dosage, structured skill progression may not matter.

• Skill training is optimal for improvement in functional goals and motor cortical plasticity.

• There may be a dichotomy between plasticity measured using tms and behavior—what does “M1 plasticity” mean?

Conclusions• How do you get to Carnegie Hall?• If you want to play the violin…• Intensity matters!• But “intensity is necessary but not sufficient” (Schertz &

Gordon 2008)• Who, what, where?• We are working with individuals• Go beyond clinical outcome measures• The key may be goal-oriented training involving motor

learning

Don’t be satisfied—we need to know so much more to optimize

rehabilitation

Systems Systems neuroscience, neuroscience, motor learning & motor learning &

controlcontrol

Neural Neural

mechanisms mechanisms

underlying underlying

movementmovement

disordersdisorders

Development and Development and

testing of rehabilitation testing of rehabilitation

protocolsprotocols

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