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
Poll Everywhere
Text REBECCAMARTI181 to 22333 once to join
www.kennedykrieger.org
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.
www.kennedykrieger.org
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
C O M P E N S A T I O N v R E S T O R A T I O N
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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;
www.kennedykrieger.org
“[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
www.kennedykrieger.org
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
www.kennedykrieger.org
Value in Restorative Interventions
• Generalizable improvements in independence
• Greater skill retention
• Reduced secondary complications and comorbidities
www.kennedykrieger.org
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
www.kennedykrieger.org
• 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
www.kennedykrieger.org
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
www.kennedykrieger.org
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.
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
ABRT?
Activity Promotes Remyelination
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
Rolling
Occupation-based Activity-based
www.kennedykrieger.org
Compensation + Restoration
www.kennedykrieger.org
Compensation + Restoration
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
Priming Paradigms
• Pharmacological priming
• Motor imagery and action observation priming
• Movement-based priming
• Stimulation-based priming
• Sensory priming
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
Priming with Patterned Activity
www.kennedykrieger.org
Priming with Patterned Activity
www.kennedykrieger.org
Sensory Priming (Vibration)
www.kennedykrieger.org
Priming with Patterned Activity
www.kennedykrieger.org
• 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
www.kennedykrieger.org
• 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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
• What do the results tell us?
– 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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
• What do the results tell us?
– 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
www.kennedykrieger.org
3 + 1 Phase Session
• Priming and preparation
• Massed practice
• Task specific practice
• Home-based training
www.kennedykrieger.org
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
www.kennedykrieger.org
Priming Interventions
Goal Good Choice Less Good Choice
Pain management TENS Heat
Tone management Vibration Stretching
Increasing available
ROM
FES as AAROM PROM
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
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
www.kennedykrieger.org
Case Study: CVA
www.kennedykrieger.org
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
www.kennedykrieger.org
Case: Relapse-Remitting MS
www.kennedykrieger.org
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
www.kennedykrieger.org
Case: SCI
www.kennedykrieger.org
Questions?