blending occupation-based and activity-based interventions ... · blending occupation-based and...

Rebecca Martin, ORT/L, OTD, CPAM

Jennifer Silvestri, OTR/L, MSOT, CPAM

Blending Occupation-based and Activity-based Interventions for Meaningful Change in Neurorehabilitation

www.kennedykrieger.org

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Objectives

At the conclusion of this session, participants will:

1. Identify differences between occupation-based and

activity-based interventions.

2. Understand how to structure treatment session to

maximize patient engagement, neurological input,

and recovery of function in patients with paralysis.

3. Assess changes in patient performance and modify

treatment plans accordingly.


International Center for Spinal Cord Injury

• 50 therapists across

the continuum of care

• Activity-Based

Restorative Therapy

• https://www.youtube.co

m/watch?v=aOk43B1s

QF0

https://www.youtube.com/watch?v=aOk43B1sQF0




C O M P E N S A T I O N v R E S T O R A T I O N


Compensation Restoration

• Scientific evidence of activity-dependent plasticity in

CNS

• Development and acceptance of rehabilitation

interventions aimed at restoration (FES, LT)

• Patients pushing previous established limits and

expectations

A Paradigm Shift


Patient Perspective: Not Good Enough

• Patients want to be near normal

• Specific environments/equipment can be limiting

• As demographic rehab skews younger, push for

community integration


Repetitions in traditional rehab

• 312 therapy sessions in post-stroke rehab

• Average duration (min) 36 (±14)

• UE (functional movement) 32

• LE (functional movement) 6

• Gait (steps) 357

• Transfers 11

Lang et al., 2009


NOT ENOUGH!

• “Amount of practice…is small compared with animal

models…Current doses…during rehabilitation are not

adequate to drive neural reorganization needed to

promote function poststroke optimally.”

Lang et al., 2009


Impact of Long-Term Disuse and Compensation

• Overuse syndromes

– Incidence of shoulder pain in SCI = 84%

– Incidence of shoulder pain 1year post stroke = 29%

• Pts. abandon equipment, resulting in caregiver

burden

• Worsening disability: Learned non-use

Alm et al. 2008; Adey-Wakeling et al., 2015;


“[In rats,] behavioral experience with the less-affected

forelimb early after unilateral [brain] lesions has the

potential to increase disuse and dysfunction of the

impaired forelimb, consistent with a training-induced

exacerbation of learned non-use. These findings are

suggestive of competitive processes in experience-

dependent neural restructuring after brain damage.”

Train the Affected Limb

Allred, et al. 2005


Long Term Skill Retention and Development

• Min assist or mod assist doesn’t really make a

difference in need for caregiver, so patients aren’t

likely to do any of the work.

• Pick a lower level skill, where you can achieve

independence

• Then aim to generalize that skill


Value in Restorative Interventions

• Generalizable improvements in independence

• Greater skill retention

• Reduced secondary complications and comorbidities


Might Take Longer for the UE

• 127 pts with mod-to-severe UE impairment, >6mos post

CVA

– Intensive robotic assisted therapy (RA)

– Intensive therapist assisted therapy (TA)

– Usual care (UC)

• Outcomes: Fugl-Meyer Assessment, Wolf Motor Function

Test, Stroke Impact Scale

• At 12 wks, RA was better than UC, but worse than TA.

Not significant differences

• At 36 wks, RA and TA were signficantly better than the US

Lo et al., 2010


• Pts who received OT 2008-2014

• More than 1 Capability of the Upper Extremity

Questionnaire (CUE) score

• Traumatic

• Adult: 41.7 (20-70)yo

• Chronic: 7.3 (1-39)yrs.

n=58

ICSCI Data Review


1pt per 100 days

-40

-20

0

20

40

60

80

100

120

140

0 500 1000 1500 2000 2500

Poin

ts o

n C

UE

Days between evaluations

Latent Change Is Possible


95

145

117

153

0

50

100

150

200

AB CDE

CU

E S

core

Start Finish

Ave. CUE Scores by AIS

Ain’t nobody got time for that.


Feasibility in In-patient Rehab

• 15 pts. with UE paralysis s/p CVA in IRF

• 4 days/week of individually tailored UE training

– Ex: lifting cans to a shelf

– Reaching, grasping, manipulating, releasing

– >/=300 reps in 60 min

• 2 days/week of ADL training

Waddell et al., 2014


Massed Practice Does Not Inhibit Skill Acquisition

• 289 repetitions/session; 47min engaged

• Fatigue was a complaint, pain was not

• Sessions were not often missed

• Improvements in ARAT, grip/pinch strength, UE-FIM

– Pts with various UE capacities could participate

– Higher doses were associated with better outcomes

– ADL retraining was not sacrificed.

Waddell et al., 2014

DEFINITIONS


Occupation-based: More Than Self-care

• Engagement in valued role-defining activities

• Intervention aimed at completion of meaningful tasks

• Modifying task, person, environment

• Traditionally more compensatory in nature


Interventoins per The Framework

Ex: Patient s/p CVA, interested in wood carving

• Prepatory Methods: Electrical stimulation for pain

control and PROM at the shoulder

• Purposeful Activity: Therapist-directed, simulated

wood carving activity

• Occupation-based Activity: Patient plans a project,

wife brings in wood and tools. Therapist modifies

task as needed to enable completion


Activity-based: More Than Exercise

• Patterned activity intended to restore a task

component

• Use near normal kinematics and conditions

• Often high volume repetition

• Aimed at recovery of motor and sensory function


Activity-based Rehabilitation

Ex: Patient s/p SCI returns to engine assembly work

• FES-assisted grasp and release activity (30 min,

~200 repetitions)

• Fine motor skill development

– Pipe fitting assembly (in-hand manipulation)

– Nuts/bolts sorting (tip/tripod pinch)

– Key board (lateral pinch with rotation)

• Patient attempts tasks at home, reports the skill

deficits which are targets for therapy


Neural Plasticity

• The capacity of the nervous system to undergo

changes in function and structure in response to use

and motor learning

• Mechanisms:

– Altered synaptic efficacy

• Increased/decreased excitability

• Unmasking of latent connections

– New Connections

• Sprouting

• Synaptogenesis

– Neurogensis


ABRT?

Activity Promotes Remyelination


ABRT? collaterals

of stalled

axons

Activity Promotes Sprouting Of Collaterals

Complete Transection

Implantable Chip

Ground Wire

FES Electrode

Peroneal Nerve

Stimulation: 3 x 1 hr per day, R / L alternate, 1 sec on /off

SCI

Suction

Ablation

T8-T10

FES

implant

BrdU

Pulse labeling

FES Activation

Interval

0 21 24 31 36

Perfusion

Cell Birth

Group

Perfusion

Cell

Survival

Group

43


0

500

1000

1500

2000

2500

3000

3500

4000

4500

Level

# C

ells

per

mm

3

C2 T7 T11 L1 L5 T1

Sham

Experimental

Injury Level

FES Induces New Cell Birth

Becker et al., Proc. Natl. Acad. Sci, 2004


Rolling

Occupation-based Activity-based


Compensation + Restoration


Best of Both Worlds

• Plan for near-term function while considering long-

term impact, ex: Tenodesis

• Addition of an AB approach elevates OB

interventions to restorative

• Intensive AB interventions are safe for all populations

PRIMING THE NERVOUS SYSTEM


What Does “Priming” Mean?

• Is defined as a change in behavior based on a

previous stimuli

• Requires repetition and appropriate dosage

• Is a tool for inducing neuroplasticity and enhancing

the effects of rehabilitation

– Low cost

– High return

– Easy to implement

• Can be categorized as a restorative intervention

• Is either modal-specific or cross-modal

• Consists of five main paradigms


Priming Paradigms

• Pharmacological priming

• Motor imagery and action observation priming

• Movement-based priming

• Stimulation-based priming

• Sensory priming


Pharmacology-based Priming

• Oldest priming tool used

• Five groups of pharmacological agents

– Amphetamines

– Dopaminergic agents

– Norepinephrines

– Cholinergic agents

– Serotonin re-uptake inhibitors

• Research primarily remains in the animal model


Motor Imagery and Action Observation Priming

• A motor task is internally rehearsed within working memory

without any overt motor output

• Priming mechanisms in the category are commonly referred to

as mental practice and include:

– Action observation

– Mirror therapy

– Computer-directed imagery

– Audio-tape generated imagery

– Therapist-directed imagery

• Mechanism: Increase in regional cerebral blood flow and

influence on corticospinal excitability

• Outcomes are greater when:

– Mental and physical practice are used in combination

– Only one upper extremity is affected

• Dosage recommendations are inconsistent


Movement-based Priming

• Defined as any repetitive or continuous movement done to

enhance therapy

• Typically includes:

– Bilateral movements

– Mirror symmetric movements

– Balance components

– Aerobic exercise

• Mechanism: Increased expression and levels of brain-derived

neurotrophic factor (BDNF) and an increase in corticomotor

excitability

• Dosage:

– 15 minutes per day

– 30 minutes of upper limb therapy


Stimulation-based Priming

• Four categories

– Transcranial magnetic stimulation (rTMS)

– Transcranial direct current stimulation (tDCS)

– Paired associative stimulation (PAS)

– Peripheral nerve stimulation (PNS)

• Dosage:

– 2-4 weeks

– 15 minutes

– 3 x per week

– Lasting effects for up to 3 months

Madhavan et al. 2012, Dafotakis 2008


Sensory Priming

• Encompasses both sensory stimulation and sensory

deprivation

• Includes:

– Temporary deafferentaiton

– Vibration

– Electrical stimulation

• Mechanism: promoting changes in the

somatosensory cortex to influence the motor cortex

to improve sensory and motor function, normalize

potentials, and reduce or promote cortical inhibition

• Dosage recommendation are mixed


Priming with Patterned Activity


Sensory Priming (Vibration)


Priming with Patterned Activity


• Objective: to determine the influence of repetitive

NMES assisted grasp and release on the paretic

tetraplegic hand

• N=3, C6-C6 SCI who were 6-21 months post

• Intervention: Grasp of 2-4 inch balls and release into

a container with NMES assist

• Dosage:

– 30 minutes/session

– 8 sessions

– 2 weeks

Evidence for Dose, Intensity, and Effectiveness: Grasp and Release

Martin, Johnston, & Sadowsky, 2012


• Results:

– Improvements were seen in grasp strength, speed, and

prehension quality

– Improvements were seen immediately post-intervention and

at study completion suggesting carry-over effect

– Significant subjective reports of increased independence and

freedom in meaningful tasks

• What do the results tell us?

– Significant improvements can be obtained in a short period

– Improvements occur quickly and exist after priming

mechanism is removed

– An improvement in one skill can translate across tasks

Evidence for Dose, Intensity, and Effectiveness: Grasp and Release


Evidence for Dose, Intensity, and Effectiveness: Upper Extremity Function

• Objective: to determine if stimulation increases

corticomotor excitability to improve hand function in

persons with cervical SCI

• N=21, 11 with SCI and 10 healthy individuals

• Intervention:

– Double-blind, crossover design

– 3 sessions, 1 hour

• transcranial magnetic stimulation (rTMS) plus repetitive

task practice (RTP)

• sham-rTMS plus RTP

Gomes-Osman & Field-Fote, 2015


Evidence for Dose, Intensity, and Effectiveness: Upper Extremity Function

• Results:

– Stimulation to prime the nervous system was only effective

when combined with training

– Improvements seen in both groups in all outcome measures


– RTP with motor priming produces results nearly 200% better

than without priming

– Meaningful improvements can be obtained immediately and

maintained

– Results were equally impressive with peripheral nerve

stimulation = THIS CAN BE EASILY DUPLICATED IN THE

CLINICAL SETTING!!!

Gomes-Osman & Field-Fote, 2015


Evidence for Dose, Intensity, and Effectiveness: Locomotor Training

• 4 Groups, N=74

– Treadmill training with manual assistance (TM)

– Treadmill training with electrical stimulation assist (TS)

– Overground training with electrical stimulation assist (OG)

– Treadmill training with robotic assistance (LR)

• Dosage:

– 1 hour/day

– 5 days/wk

– 12 wks

Field-Fote & Roach, 2011


Evidence for Dose, Intensity, and Effectiveness: Locomotor Training

• Which group did best?

– Overground training with electrical stimulation assist (OG)

– All groups improved and even maintained a portion of their

improvements at follow-up


– The groups that used priming during a motor intervention did

better

– Using more than one priming intervention was superior

– If you want to improve a skill, you need to practice all

components of the skill, even the difficult ones

Field-Fote & Roach, 2011

SESSION STRUCTURE


3 + 1 Phase Session

• Priming and preparation

• Massed practice

• Task specific practice

• Home-based training


Priming and Preparation

• Use activities/modalities targeted at increasing neural

excitability and preparing the physical system

• Nervous system is engaged, not a passive process

• May need a boost later in the session


Priming Interventions

Goal Good Choice Less Good Choice

Pain management TENS Heat

Tone management Vibration Stretching

Increasing available

ROM

FES as AAROM PROM


Massed Practice

• Therapist directed, repetitive activities aimed at

improving a component

– Stacking task

– Card flipping

– Small assembly tasks

• Promote cortical reorganization: in CIMT, benefits

result from frequency of use of involved side, not

constraint of uninvolved side

• Improve strength and ROM

• Perfect practice makes perfect


Strategies to Incorporate

• Breakdown functional skills

– Repeat half roll

• Facilitation techniques

– PNF to encourage mass flexion

• Combine with other components

– FES to abs

• Technology where appropriate

– Balance benefit

– Don’t want to build reliance on


Don’t Let Bad Habits Persist

• Use it or lose it: Abhorrent patterns and compensatory strategies have to be overcome by rehabilitation

• Patients will figure out how to get things done (ex: tenodesis)

• Cortical reorganization responds to non-use as much as therapy

• The body learns what we teach it


Task Specific Practice

• Practice of context specific motor tasks

• Training functional task rather than impairment

• Paired with feedback

• Goal directed

• Incorporate priming strategies

– Stand at sink to brush teeth

– High repetitions of elbow flexion followed by self-feeding

CASE STUDIES


Case: CVA

• 53 yo male s/p left MCA ischemic stroke secondary

to dissected internal carotid artery. Recovery

complicated by multiple seizures.

• Right hemiplegia, hypertonicity, expressive aphasia,

mild receptive aphasia, right neglect, and complex

apraxia.

• Goals:

– Strengthen (R) elbow and wrist for ADLs

– Improve bed mobility

– Step in to shower safely

– Ascend/ descend stairs safely


Case Study: CVA


Case: Relapse-Remitting MS

• 56 year old, left handed, male diagnosed with

relapsing remitting MS.

• Symptoms included: left leg weakness, decreased

ADL independence, balance impairments,

hypertonicity, decreased coordination, and dysarthria.

• Goals:

– To stand and walk again independently

– To be able to get up and down off of the floor independently

– To be able to play with his children (piggy back rides,

basketball)

– To prepare a hot meal on stovetop/oven


Case: Relapse-Remitting MS


Case Study: SCI

• 64 year old, right handed male diagnosed with

incomplete central spinal cord injury secondary to fall

from bicycle (C3 AIS D)

• Symptoms include right rotator cuff tear, left ulnar

nerve compression, balance impairment, bicipital

tendonitis, and left ear hearing loss

• Goals:

– Decrease shoulder pain

– Increase bilateral grip strength to open containers

– Increase independence


Case: SCI


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blending occupation-based and activity-based interventions ... · blending occupation-based and...

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