REHABILITATION AND NEUROPLASTICITY A practical approach Elissa Held Bradford, PT, PhD, NCS, MSCS NMSS 2018 Regional MS Summit
REHABILITATION AND NEUROPLASTICITY
A practical approach
Elissa Held Bradford, PT, PhD, NCS, MSCSNMSS 2018 Regional MS Summit
Objective
Apply neuroplasticity principles to design a rehabilitation patient-centered evidence-based plan of care that maximizes restorative potential and neuroplasticity in MS
Neurons that fire together wire together
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AUDIENCE POLLYears of clinical experienceProfessional background
Number of individuals living with MS seen/yearWays you promote neuroplasticity in your practice
Outline
■ Neuroplasticity principles in rehab■ Decision-making for application of principles■ Clinical examples■ Monday morning …
■ THANK YOU… Randy Karmin PT, DPT, NCS, CBIS & Alicia Flach, PT, DPT, NCS
NEUROPLASTICITY PRINCIPLES IN
REHABILITATION
Neuroplasticity & Neuroprotection
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Neuroplasticity in motor training and motor learning■ Learning a skill
– Initially uses numerous regions of the brain■ Increased cognitive demand/attention
(cognitive stage)– As skill of task or movement increases
(associative to automatic stages) decreased areas of brain are activated■ Refined and efficient ‘algorithm’ or activation
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Brain Training
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The BIG 10
DECISION MAKING FOR APPLICATION OF
PRINCIPLES
An evidence-based approach to promote neuroplasticity in MS
http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036021
Social Cognitive Theory
Self-Management-goal setting
-action planning-self-monitoring
-self-efficacy-applying strategies to
break the symptoms cycle
Neuroscience & Motor Learning
Task-Oriented Functional Training-meaningful task practice
-high repetition-challenging-progression
-problem solving-self-evaluation
Self-Management and Task-Oriented Approach to Rehabilitation Training (START)
Summary of Fig. 2 Richardson et al. 2015 Phys Ther
PersonTask
Environment
Table S2- Therapist Cue Card eSupplement-Richardson et al. 2015 Phys Ther
How do I promote neuroplasticity in my practice? Optimizing Movement Programs (OMP)
■ Relevant, Engaging, Meaningful■ Task-specific (job,
hobbies, daily activities)■ (Mod to) High intensity■ High repetitions
■ Instructions, Feedback ■ Environment (sensory)■ Attention (focused vs.
divided; stage of motor learning)
■ Errorless vs. Error-based■ Performance vs Learning
Optimizing Neuroplasticity & Motor Learning
Physical Assistance Feedback Intensity: Type and level of challenge varies based on
degree of skill acquisition and stage of motor learning
Intensity
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Can I apply this in MS? YES
Acro
ss D
isabi
lity
Leve
lsRe
stor
ativ
e ap
proa
ch in
MS
EDSS 0-3.5Little disability
EDSS 4-5.5Mild disability
EDSS 6.0-7.5Moderate disability
EDSS 8.0-9.5Severe disability
Promote active lifestyleMaintain mobilityMaintain participation
Promote active lifestyle, adaptations as needed
Promote maintenance of mobility and active lifestyle
Maintain focus on rehab strategies for deficits as able
Task-specific training (gait, balance, reach)
Task-specific training (gait, balance, reach)
Modify tasks and activities
Address pertinent and specific underlying impairments
Address pertinent and specific underlying impairments
Address pertinent and specific underlying impairments, with energy conservation methods - intermitten exercise
Implement energy conservation methods
Adapted from PTNow.org -Clinical summaries
PT DECISION MAKING IN
ASSESSMENT AND
INTERVENTION PLANNING IN
MSHeld Bradford et al. 2017 Disability and Rehab
Dose (FITT) FrequencyIntensityTimingType
PWMS DECISION MAKING
AND ACTIONS
Held Bradford et al. 2017 Disability and Rehab
Dose - FITT
■ Active ingredient
■ Mechanism of action
■ Half-life
Operational definitions from Basso M., Lang C. JNPT 2016https://exerciseismedicine.org/assets/page_documents/EIM%20Prescription%20pad%202-up.pdf
http://www.csep.ca/CMFiles/Guidelines/specialpops/CSEP_MS_PAGuidelines_adults_en.pdfLatimer-Cheung, A. E., Martin Ginis, K. A., Hicks, A. L., Motl, R. W., Pilutti, L. A., Duggan, M., . . . Smith, K. M. (2013). Development of evidence-informed physical activity guidelines for adults with multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 94(9), 1829-1836. Latimer-Cheung, A. E., Pilutti, L. A., Hicks, A. L., Martin Ginis, K. A., Fenuta, A. M., MacKibbon, K. A., & Motl, R. W. (2013). Effects of exercise training on fitness, mobility, fatigue, and health-related quality of life among adults with multiple sclerosis: A
systematic review to inform guideline development. Archives of Physical Medicine and Rehabilitation, 94(9), 1800-1828.
Dose
CLINICALEXAMPLES
Principles: Timing, Age, Use It or Lose It, Use It & Improve It --- Building Reserve■ Neuroprotective effect of exercise & physical activity in MS
Giesser B. Ther Adv Neurol Disord 2015
■ Cognitive reserve hypothesis Sumoski. Front Neuro 2015
The Power of Prevention & Early Interventione
Handout – How neuroplasticity works - https://www.nicabm.com/brain-how-does-neuroplasticity-work/
Handout – How neuroplasticity works - https://www.nicabm.com/brain-how-does-neuroplasticity-work/
Principle: Transference ---Prime the Movement System
Mang, Cameron S et al. “Promoting neuroplasticity for motor rehabilitation after stroke: considering the effects of aerobic exercise and genetic variation on brain-derived neurotrophic factor.” Physical therapy 93 12 (2013): 1707-16.
Principle: Transference, not Interference ---It Adds Up
Use Mirror Neurons Acharya et al. 2012
■ Mental practice■ Observational practice ■ Mirror training
Principles: Intensity, Repetition, Specificity, Salience
Principles: Intensity, Repetition, Specificity, Salience - Assisted
Principle: Intensity – Trial & Error/ Active Learner
Assisted
Error Augmentation
Principles: Intensity - Weighting
Inte
nsity
–RP
E Sc
ale
Noble BJ, Borg GAV et al. 1983 In Nieman DC. Exercise testing and prescription : a health-related approach. 7th ed. Boston: McGraw-Hill; 2011
Morrison EH, Cooper DM, White LJ, et al. Ratings of perceived exertion during aerobic exercise in multiple sclerosis. Arch Phys Med Rehabil. Aug 2008;89(8):1570-1574.
Motl RW, Goldman MD, Benedict RH. Walking impairment in patients with multiple sclerosis: exercise training as a option. Neuropsychiatric disease and treatment. 2010;6:767-774.
15-Category RPE Category-Ratio RPELight Intensity
6 No exertion at all 0 Nothing at all
7 Extremely light 0.5 Very, very weak (just noticable)8
9 Very light 1 Very weak10 2 Weak (light)11 Light 3 Moderate
Moderate Intensity 12 4 Somewhat strong
13 Somewhat hard 5 Strong (heavy)
Vigorous Intensity14 615 Hard (heavy) 7 Very strong16 8
17 Very hard 9
18 10 Very, very strong (almost max)
19 Extremely hard
20 Maximal exertion • Maximal
Start with light tomoderate,
11-13, especially if deconditioning and fatigue
present, then increase challenge as tolerated, max 15-17 (Motl et al.
2010)
Principles: Intensity, Repetition, Specificity, Salience - Environment
Principle: Intensity---AttentionFocused Attention –Cognitive stage
Divided Attention- Dual TaskAssociated-Automatic stage
Principles: Intensity, Repetition, Specificity---Instructions, Feedback
■ Less is more■ External focus■ Stage of Learning
Principles: Repetition, Intensity, Specificity, Salience – Can learn & apply from CIMT & LSVT BIG to MS?■ Meaningful massed task specific practice
■ 5 days per week x 4 weeks
■ Shaping for progression of intensity of task practice
■ Modeling
■ Transfer package for home engagement
Mark et al. Constraint Induced Movement Therapy for the Lower Extremities in Multiple Sclerosis: Case Series with 4-Year Follow up. Archives of Physical Medicine and Rehab 2013
But do we really know as much as we think we know ?
Lang CE, Strube MJ, Bland MD, et al. Dose-response of task-specificupper limb training in people at least 6 months post stroke: a phase II,single-blind, randomized, controlled trial. Ann Neurol. 2016;80(3):342-354
Lang. C IV step conference 2016
Metacognition
Professional resources■ Consortium of MS Centers – www.mscare.org
– Offers MS specialist certification to AHPs (MSCS)– MS peer reviewed journal - IJMSC– PT & SPT – 5 day fellowship through IOMSRT
www.iomsrt.mscare.org■ euRIMS – www.eurims.org■ ANPT – www.neuropt.org
– Degenerative disease SIG -http://www.neuropt.org/special-interest-groups/degenerative-diseases
– Neuro list serve (yahoo group) ■ National Multiple Sclerosis Society – www.nmss.org
WHAT 3 THINGS CAN YOU APPLY TO CLINICAL
PRACTICE ON MONDAY?
THE TAKE AWAY
In summary…§ Remember ‘Neurons that fire together wire
together’§ Know the BIG 10 of neuroplasticity§ Think dose – FITT§ Fill your toolbox of resources§ Practice metacognition
This Photo by Unknown Author is licensed under CC BY-NC-ND
THANK YOU
Questions?elissa.heldbradford@
health.slu.edu