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

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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