Dr. Wael Alasaq Aug. 20051 Stroke Rehabilitation Wael Alasaq PT, PhD. Kuwait University Physical Therapy Dep

Dr. Wael Alasaq Aug. 2005 1

Stroke Rehabilitation

Wael Alasaq PT, PhD.Kuwait University

Physical Therapy Dep.


• Theory

• The importance of theories

• Motor control

• Motor learning


Bases for rehabilitation

What is a theory?

• An abstract idea that provide an answer or a description about a phenomenon.

• Motor control theories are abstract ideas about the nature and cause of movement.


• Why do we use theories? What is the importance theories?


What is motor control theory?

• Motor control: is the study of the nature and cause of movement.

• Theory of motor control: is a group of abstract ideas about the nature and cause of movement. Theories are often, but not always, based on models of brain function.


Why there are many theories?

• For explaining

• Answering what is messing from others

• New discoveries


How theories affect rehabilitation?

In the past:

• CNS is thought of as rigid and unalterable.

• Regeneration & reorganization was not possible within the CNS.

• Treatment focus was on the use of what ever movement available (leading to compensation)


How theories affect rehabilitation?

Currently:• More recent research in the field of

neuroscience show that adult CNS has great plasticity and an incredible capacity of reorganization.

• Thus ttt focus is on recovery ( achieving task goals using effective & efficient means, but not necessarily those used premorbidly)


Theories of motor control & motor learning

• Reflex theory• Hierarchical theory• Motor programming Theory• Systems theory• Dynamical action theory• Parallel distributed processing theory• Task-Oriented theory• Ecological theory


Motor learning

• Motor learning: the study of the acquisition & modification of movement.


Motor learning theories

• Adam’s Closed-Loop theory

• Schmidt’s Schema theory

• Fitts & Posner: Stages of motor learning

• Newell’s theory of learning as exploration


Brain reorganization & Functional recovery

• To date there is no medical intervention to reduce the extent of neural damage following stroke.

• How can we then improve functional outcome?


Brain reorganization & Functional recovery Cont.

• Neural system is being remodeled throughout life & after injury by experience & in response to activity and behavior (Jenkins et al. 1990, Johansson 2000, Nudo et al. 2001)



• Hebb (over half a century ago) suggested that neural cortical connections can be remodeled by our experience.



• Foundation for functional plasticity:– There is an extensive overlapping of muscle

representation within the motor map, with individual muscle & joint representations re-represented within the motor map

– Individual corticospinal neurons diverging to multiple motoneuron pools.

– Horizontal fibers interconnecting distributed representations. (Nudo et al. 2001)



• Changes in the nervous system may occur according to the patterns of use. (Pascual-Leone & Torrres 1993)

• These studies stress the changes associated with active, repetitive training & practice, & by the continued practice of the activity.

• Restriction of activity or disuse associated with immobilization or amputation causes alterations in the cortical representation (reduction). (Leipert et el. 1995)



• This suggests that the neural system is flexible and adaptive, and respond to many factors, including patterns of use.



• The current technology of imaging systems have confirmed that:– the cerebral cortex is functionally and

structurally dynamic– neural reorganization occurs in human cortex

after stroke – Altered neural activity patterns and molecular

events influence this functional reorganization (Johansson 2000)



Two types of processes underlying functional recovery following stroke:

1.Reorganization of affected motor regions– Changes in membrane excitability– Growth of new connections or unmaking of pre-

existing connections– Removal of inhibition and activity-dependent synaptic

changes– Plastic changes in subcortical regions.

2. Changes in the unaffected hemisphere.



• Importance of active use of the limb for the survival of the undamaged neuron adjacent to those damaged by cortical injury & that retention of the spared hand area & recovery of function after cortical injury might depend upon repetitive training and skilled use of the hand.



• There is relationship between PT intervention and reorganization of the cerebral cortex.

Lieper et al. (2000)

• Usually the recovery of function starts 3-4 weeks. During these 3-4 Wks there is resolution of edema, absorption of necrotic tissue debris and the opening of collateral channels for circulation to the lesioned area.


The Rehabilitation Environment

The reorganization & functional recovery from brain lesion are dependent on 3 factors:

1.Use

2.Activity

3.Environment in which the rehabilitation is curried out.


The Rehabilitation Environment cont.

The rehabilitation environment is made up of:

1. The physical built environment (physical setting)

2. The method used to deliver rehabilitation

3. The staff, their knowledge, skills & attitudes.


Time spent on Activity


Structuring a Practice Environment

The goals of PT intervention are to provide:1.Opportunities for an individual to regain optimal skilled

performance of functional actions

2. to increase level of strengths

3. to increase level of endurance

4. to increase level of physical fitness

• Emphasis should be placed on the time spent on practice as well as the type of practice

(Small & Solodkin 1998)


Delivery of Physiotherapy

• Independent practice

• Group practice


Group exercise & training

What kind of benefits it has on therapist, patient and training program?

What are the factors that may influence the amount of independence practice?– Patient's level of disability– Willingness by the pt– Understandability of the exercise to be curried

out


Group exercise & training Cont.

How to encourage understandability?– Brief explanation with demonstration– List of diagrams– Workbook– Feedback (verbal, graphs, number, speed

etc)– Personalized according to pt's needs &

situation


Group exercise & training Cont.

Why do we need to increase time spent in exercise?– Improve physiological responses, such as

endurance, strength, and fitness.– Improve functional motor performance (more

repetitions leading to mastering the skill)– Achieve goals of the treatment


Optimizing skill

What is a skill?

A skill is:

• 1- "Any activity that has become better organized & more effective as a result of practice” (Annett 1971)

• 2- "The ability to consistently attain a goal with some economy of effort“

(Gentile 1987)


Optimizing skill Cont.

How to optimize a skill?

• Braking the movement down into its segmental constituents

• Task oriented training to gain the necessary control

• Through training and repetition muscle motor learning is taking place and more strength is gained.


Optimizing skill Cont.

Stages of learning skills:– Cognitive stage ( getting the idea of the

movement)– Intermediate or associative stage (preparing

for adaptation of the movement pattern) – Final or autonomous stage (owning it,

mastering it)


Optimizing a skill Cont.

Factors for optimizing a skill: a- focusing attention

b- Provision of feedback

c- Transfer of learning

d- Practice


A- Focusing attention

Learning of motor skills involves:

• Identifying what is to be learned.

• Understanding the ways for goal accomplish


Identifying what is to be learned

• Two methods for directing the focus of attention1.Demonstration (live & recorded) (Fig 1.4)

2.Verbal instruction• Should be brief• Simple (no too much details, U will kill him)• In a language that is understood by the patient (Fig

1.5)


Understanding the ways for goal accomplish

Setting goals, should be:

• Meaningful

• Reasonably challenging but yet attainable


b- Feedback

• Very important for skill acquisition about performance.

• There are two types of feedback, intrinsic and extrinsic (augmented)

• Intrinsic, is the sensory feedback (visual, proprioceptive, tactile)

• Extrinsic (Augmented) feedback provide knowledge of the result of action (KR) and knowledge of the performance (KP), such as therapist or instrument (e.g. EMG)


C- Transfer of learning

• Transfer training (learning) from practice environment (rehabilitation setting) to other environments.

• A closed motor skill vs. Open motor skill


d- Practice

• Optimizing performance through repetition in order to increase strength, skill development as well as training for muscle coordination.


d- Practice Cont.

Discuss how would you keep patients

motivated during practice, as it involves

repetition of actions?


d- Practice Cont.

Remember:

Patients need to practice in different

contexts in order to develop flexibility to

apply motor tasks into different

environment..

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Dr. Wael Alasaq Aug. 20051 Stroke Rehabilitation Wael Alasaq PT, PhD. Kuwait University Physical Therapy Dep