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

2. Dr. Wael Alasaq Aug. 20052 Theory The importance of theories Motor control Motor learning

3. Dr. Wael Alasaq Aug. 20053 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.

4. Dr. Wael Alasaq Aug. 20054 Why do we use theories? What is the importance theories?

5. Dr. Wael Alasaq Aug. 20055 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.

6. Dr. Wael Alasaq Aug. 20056 Why there are many theories? For explaining Answering what is messing from others New discoveries

7. Dr. Wael Alasaq Aug. 20057 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)

8. Dr. Wael Alasaq Aug. 20058 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)

9. Dr. Wael Alasaq Aug. 20059 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

10. Dr. Wael Alasaq Aug. 200510 Motor learning Motor learning: the study of the acquisition & modification of movement.

11. Dr. Wael Alasaq Aug. 200511 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

12. Dr. Wael Alasaq Aug. 200512 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?

13. Dr. Wael Alasaq Aug. 200513 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)

14. Dr. Wael Alasaq Aug. 200514 Brain reorganization & Functional recovery Cont. Hebb (over half a century ago) suggested that neural cortical connections can be remodeled by our experience.

15. Dr. Wael Alasaq Aug. 200515 Brain reorganization & Functional recovery Cont. 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)

16. Dr. Wael Alasaq Aug. 200516 Brain reorganization & Functional recovery Cont. 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)

17. Dr. Wael Alasaq Aug. 200517 Brain reorganization & Functional recovery Cont. This suggests that the neural system is flexible and adaptive, and respond to many factors, including patterns of use.

18. Dr. Wael Alasaq Aug. 200518 Brain reorganization & Functional recovery Cont. 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)

19. Dr. Wael Alasaq Aug. 200519 Brain reorganization & Functional recovery Cont. 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.

20. Dr. Wael Alasaq Aug. 200520 Brain reorganization & Functional recovery Cont. 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.

21. Dr. Wael Alasaq Aug. 200521 Brain reorganization & Functional recovery Cont. 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.

22. Dr. Wael Alasaq Aug. 200522 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.

23. Dr. Wael Alasaq Aug. 200523 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.

24. Dr. Wael Alasaq Aug. 200524 Time spent on Activity

25. Dr. Wael Alasaq Aug. 200525 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)

26. Dr. Wael Alasaq Aug. 200526 Delivery of Physiotherapy Independent practice Group practice

27. Dr. Wael Alasaq Aug. 200527 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

28. Dr. Wael Alasaq Aug. 200528 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

29. Dr. Wael Alasaq Aug. 200529 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

30. Dr. Wael Alasaq Aug. 200530 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)

31. Dr. Wael Alasaq Aug. 200531 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.

32. Dr. Wael Alasaq Aug. 200532 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)

33. Dr. Wael Alasaq Aug. 200533 Optimizing a skill Cont. Factors for optimizing a skill: a- focusing attention b- Provision of feedback c- Transfer of learning d- Practice

34. Dr. Wael Alasaq Aug. 200534 A- Focusing attention Learning of motor skills involves: Identifying what is to be learned. Understanding the ways for goal accomplish

35. Dr. Wael Alasaq Aug. 200535 Identifying what is to be learned Two methods for directing the focus of attention 1.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)

36. Dr. Wael Alasaq Aug. 200536 Understanding the ways for goal accomplish Setting goals, should be: Meaningful Reasonably challenging but yet attainable

37. Dr. Wael Alasaq Aug. 200537 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)

38. Dr. Wael Alasaq Aug. 200538 C- Transfer of learning Transfer training (learning) from practice environment (rehabilitation setting) to other environments. A closed motor skill vs. Open motor skill

39. Dr. Wael Alasaq Aug. 200539 d- Practice Optimizing performance through repetition in order to increase strength, skill development as well as training for muscle coordination.

40. Dr. Wael Alasaq Aug. 200540 d- Practice Cont. Discuss how would you keep patients motivated during practice, as it involves repetition of actions?

41. Dr. Wael Alasaq Aug. 200541 d- Practice Cont. Remember: Patients need to practice in different contexts in order to develop flexibility to apply motor tasks into different environment..