Training Techniques to Enhance Neuroplasticity

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Training Techniques to Enhance Neuroplasticity

• Society of Alberta Occupational Therapists,
• AGM
• October 18, 2008
• Cherie Henderson, BScOT
• Glenrose Rehabilitation Hospital
• Outpatient Stroke Service

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Learning Objectives

• 1. Describe injury and use dependent
  neuroplasticity.
• 2. Relationship to Constraint Induced Movement
  Therapy (CIMT).
• 3. Instruct in technique for Shaping (adapted
  task practise).
• 4. Provide hands on practise in Shaping
  techniques.

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Neuroplastic Changes

• Can be Injury dependent or Use dependent
• When there is an injury, such as a stroke, there
  is reduction of cortical representation area of
  paretic muscles and a reduction in motor cortex
  excitability. This may be due to
  neurophysiological changes and/or non-use!
• However, the same is true of use or experience
  it can increase cortical representation

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Principles of Experience-dependent Plasticity
Kleim Jones

• 1. Use It or Lose It Failure to drive specific
  brain functions can lead to functional
  degradation.
• 2. Use It and Improve It Training that drives a
  specific brain function can lead to an
  enhancement of that function.
• 3. Specificity The nature of the training
  experience dictates the nature of the
  plasticity.
• 4. Repetition Matters Induction of plasticity
  requires sufficient repetition.
• 5. Intensity Matters Induction of plasticity
  requires sufficient training intensity.

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Principles of Experience-dependent Plasticity
Kleim Jones (continued)

• 6. Time Matters Different forms of plasticity
  occur at different times during training.
• 7. Salience Matters The training experience
  must be sufficiently salient to induce
  plasticity.
• 8. Age Matters Training-induced plasticity
  occurs more readily in younger brains.
• 9. Transference Plasticity in response to one
  training experience can enhance the
  acquisition of similar behaviors.
• 10. Interference Plasticity in response to one
  experience can interfere with the acquisition
  of other behaviors.

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CIMT is a Family of Therapies
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Repetitive, Task Specific Training can induce
neuroplastic changeLiepert et al, 2000

• Liepert et al. (Stroke. 2000311210-1216)

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How much is enough??
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Rationale for Shaping

• Most research on neuroplasticity focuses on
  massive amount of repetitions (tens of
  thousands!)
• Observational study by Lang et al found average
  of repetitions for UE exercise between 12-38
  repetitions per session (average session 36 /-14
  minutes)
• One method to increase the number of repetitions
  for patients who have sufficient motor ability is
  through SHAPING.

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Shaping (Adapted Task Practice)

• a training method by which a motor or behavioural
  objective is approached in small steps.
• Goal is not skill acquisition but cortical
  reorganization!
• Tasks are selected the same as you would any
  training method (what movements are needed,
  where is the best potential for improvement,
  patient goals and preference).

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Method

• 1. Pick the activity you want to work on.
• -what movement goals, patient goals, etc
• 2. Design a 30-45 second trial.
• -how long does it take to move 5 cones?
• -how many cones can be moved in 30 seconds?
• 3. Provide feedback, coaching, modeling, etc
• 4. Repeat trial ten times.
• 5. Keep track of quantity (ie. time, number) but
  also quality of movement.

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• 6.Next time you try the activity, complete 5
  trials.
• 7. Based on improvement (quantitative and
  qualitative), decide if you want to shape or
  grade the activity.
• -There are no rules about progression - use your
  professional judgment. ie more cones, change
  position, smaller cones
• 8. Complete the last 5 trials.

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Conclusions

• neuroplasticity is dependent on intense,
  task-specific, repetitive activities
• the number of repetitions in traditional therapy
  does not approach the threshold for intensity
• we need to consider the dosing of our therapy
• Shaping is a training technique designed to
  provide extended, concentrated massed practice

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References

• Liepert J, Bauder H, Miltner WH, Taub E ,
  Weiller C. Treatment-induced cortical
  reorganization after stroke in humans. Stroke
  2000 31 1210-1216.
• Kleim JA Jones TA. Principles of
  experience-dependent neural plasticity
  implications for rehabilitation after brain
  damage. Journal of Speech, Language, and Hearing
  Research . 2008 51 S225S239.
• Morris DM, Taub E, Mark VM. Constraint induced
  movement therapy characterizing the intervention
  protocol. Eura Medicophys. 200642(3)257-68.
• Lang CE, MacDonald JR, Gnip C. Counting
  repetitions an observational study of outpatient
  therapy for people with hemiparesis post-stroke.
  J Neurol Phys Ther. 2007 31 3-10.