Neuroplasticity: Evidence Based

Clinical Applications

Christina Lighthill, MOT, OTR

Rachel Atkins, PT, DPT

Objectives

1.Concept of neuroplasticity

2.Essential principals• Basic theories and principles

• History

• Positive vs. Maladaptive neuroplasticity

3. Recent evidence • Incorporate recent evidence into clinical application

• Eliciting good neuroplastic changes

• Share research articles

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Objectives (cont.)

4. Evidence based interventions • Explain enriched environment

• Provide a description of environmental structure that Pate provides in

accordance with neuroplasticity principles

• Present interventions to promote brain activation

• Present future possibilities

5. Evaluation and Discussion• Facilitate questions and discussion

• Handout evaluation form

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Neuroplasticity

History of science•450 BC- Greek physician brain dissections led to discovery that heart was not the center of intelligence.

•1861- Dr. Broca’s autopsies revealed people with speech problems had brain damage in the lateral frontal lobe. 1874- Wernicke’s area discovered to control interpretation of written and spoken language.

•1950s- Treated epilepsy by electrically zapping to destroy part of brain causing seizures, Created maps of sensory & motor maps still used today. Over the years- neuroscientists began plotting areas of the brain as ONLY controlling a specific function- no changing.

•1980s-90s-Taub experiments on animals show that if given purposeful brain injury resulting in hemiparesis, that the brain can reorganize itself to recover the lost function of a limb if the environment demands it. THE BRAIN CAN CHANGE

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Defined: The property of the brain to adapt to environmental pressure, experiences, and challenges including brain damage14. Life long capacity of the brain to change and rewire itself in response to the stimulation of learning and experience.

Functional MRI

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Cortical Mapping

Broadmann’s Areas Homonculus

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Targeted Training for Positive Neuroplasticity

•Use it or lose it •Keep control of real estate•Prevent a take over

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“One practice variable that

dwarfs all the others in terms of

importance and is so obvious

that it need hardly be

mentioned at all- practice”.

-Schmidt and Lee

Essential Principals of

Neuroplasticity

Brain Injury Rehab

BI is the leading cause of chronic disability.7

• Cognition- one study showed that 91% of survivors

failed in at least one cognitive domain, mainly: memory

and executive functions.

•Language- 25-40% of CVA survivors have aphasia.

•Physical- Two-thirds of survivors have impaired gait and 6 months late more

than 30% still need assistance to walk. 80% of stroke survivors have

hemiparesis. In 2005, nearly 1.1 million stroke survivors reported difficulty

performing basic activities of daily life.

Cost• The annual cost of TBI to society exceeds $76.5 Billion.

• The estimated cost of stroke in the United States was $53.9 billion in 2010.

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Environmental Design

• Duration & Intensity

• Structure and Distraction

• Multidisciplinary

• External Support Systems

• Therapeutic Use of Self

Influences on Neuroplasticity

•Time since onset

•Age

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Brain Injury Rehab

The benefit is a combination of optimal care,

task oriented, and meaningful training in an

environment that gives confidence, stimulation,

and motivation. Environmental enrichment has

many functional and biological effects and

significantly enhances the effect of other

interventions.

–Johansson, BB.

Enriched Environment

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Promoting Neuroplasticity in an Enriched Environment

We do this 3 ways:

1.Social stimulation

2.Interaction with objects

3.Physical activity dependent

Emotional Climate

• Interaction with therapists

and other survivors

•Relaxation/Stress management

•Sleep

EE: model that provides multiple possibilities

•Client Driven

Schedules

•Job Task Simulation

•Work site evaluations

• Community &

Home Based Treatment

Functional Approach in an Enriched Environment

Considerations for Acute and Inpatient Rehab15

The brain is vulnerable in the first 7 days post injury

•Managed care wants functional changes

•Fine line to discover the ideal challenge to prevent complications and

also to promote functional changes to create optimal rehab opportunities

Evidence

In animal models:

•Voluntary exercise in the first 7 days decreased plasticity.

•Voluntary exercise in days 14-20 after injury increased plasticity.

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Enriched Environment Enhances other Interventions,

but on its own.. 15, 16

Functional Effects

•Improves working memory, spatial

learning

•Greater opportunity to engage in

stimulating activities- motor

•Meeting new people/creating

relationships helps restore language,

emotional intelligence, and sense of self

•Promotes independence through task

specific activities of daily living

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Biological Effects= MORE

•Dendrites

•Dendritic branching

•Synapses

•Glial processes

•Brain weight

•Cortical thickness

• Task Specific

• Repetitive

300-1000 per day!

• Relevant

• Engaging: Multisensory

Interaction,

Biofeedback

• Challenging and

Progressive

Structuring Interventions13

Evidence Based Therapeutic

Interventions

Aerobic Exercise

Basic description: any activity that uses large muscle groups, can be maintained continuously,

and is rhythmic in nature. It is a type of exercise that overloads the heart and lungs and causes

them to work harder than at rest.8

Parameters: 3-7 days/wk, 20-60 minutes (can be broken into 10 minute increments), 50-80%

of HRmax1

Clinical applications: Even when a pt may not present with need for skilled PT/OT, they need

to have an aerobic ex program for ideal healing, prevention, cognitive benefits. Needs to be part of

the recovery program. If possible do it before cognitive tx.

Considerations: Releases BDNF, promotes neurogenesis & angiogenesis

• Decreased incidence of depression, greater chances for social interaction, improved emotional

function, better QOL

• Positive impact on attention/concentration, executive function, memory, visual-perceptual deficits,

language deficits. 2

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Aerobic Exercise2

Reference #219

Bilateral Arm Training14

Basic description: “Good trains the bad”,

promotes lateralization- activation undamaged side

increased activation of damaged hemisphere. Shown to reduce motor

impairment & improve spatiotemporal control of affected arm in both bilateral

and unilateral tasks.

Parameters: 2hrs/day, 5 days a week for 3 weeks. 1 hr/day, 2 wks Effective in

subacute & chronic phases. Bilateral movement alone or paired with rhythmic

auditory cuing or estim.

Clinical applications: 6-67months after onset. (proven superior to traditional

equally intense but less task specific therapy). Greater gains in proximal upper

limb than traditional and CIMT .

Considerations: Good for severe functional deficits and at all levels.

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Constraint Induced Movement Therapy

Basic description: forced use of the affected extremity by

limiting use of the non affected extremity with mitt or other

constraint device 17, 13

Parameters: Therapy 5 hrs/day + wear mitt 90% of waking hrs. 10-15 days

mCIT Therapy ½ hr, 3X/wk + forced use- 5 hrs/day, 5 days/wk during active

productive times . Other protocols - 1-6 hrs/day, 3-5 days/week, 2-12 weeks13. 6 hrs/day, 7days/wk, for 2 wks.11

Clinical applications: effective 3-21 mo. post injury17 . Mild-mod impaired14.

Higher intensity in acute care =negative effects.

Considerations: Must meet inclusion criteria (washcloth or towel test); client

must be fully vested, behavioral contracts are common. In animal models,

forced use in the first 7 days compounded the injury and led to decreased

function.

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Body Weight Supported Treadmill Training

Basic description: A task-specific intervention that is used to provide

an environment that facilitates relearning normative gait after stroke.9

Parameters: No GT in acute care, 30 mins/day, 5 days/wk for 2-8

weeks with double upright AFO. Initial BWS 30%, speed .7 mph, no UE support, 2

therapists- one for weigh shift, other for limb advancement. After 2 consecutive bouts

of at least 3 minutes, speed was increased by .1 mph and BWS decreased by 5%

until pt reached 10 mins at 1.5 mph with 0 BWS and minA or less for involved leg

advancement. Overground gait use of STC. (all s AFO/AD by 6 months post).10

Clinical applications: Start in inpatient rehab, if BWS unavailable, use B platform

walker and rolling stool. Must be able to sit independently for 3 minutes and stand

with or without assistance.

Considerations: One prelim study on chronic CVA shows overground may be

superior to BWS.

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Mirror Therapy

Basic description: a mirror is placed at 90 degrees close to the midline of the pt and the

affected limb is positioned behind the mirror. The pt watches the non-affected limb in the

mirror and performs exercises. Receiving positive visual impression that the limb in the

mirror (the affected limb) is fully functioning.

Parameters: 1 hr/day in addition to conventional rehab5. Chronic CVA- 1.5 hrs/day, 5

days/week, 4 weeks. Chronic- regain more distal function vs. traditional tx14 . 15 min

2X/day, 6 days/wk- proximal-> distal.

Clinical applications: beneficial for sensory deficits &

simulates recovery from hemi-neglect. Improved

performance in all measures, but not necessarily ADLs6.

Related to action observation as it activates motor and

premotor areas. Multi-sensory interaction. Cortical changes

even when no movement in the affected limb!

Considerations: Low cost. Ability to carry over at home .

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Action Observation

Basic description: Watching the performance of someone else or themselves on a video.

The actions are automatically mapped into the motor system without sophisticated

perceptual analysis (mirror neurons). Combine observation of daily action with physical

training of the same movements14.

Parameters: 4 weeks- significant enhancement of motor activation in pre-motor cortex14.

Clinical applications: good priming task, providing feedback on performance, all levels of

severity, easy. Gestures may facilitate word retrieval in aphasia. Listening to speech

actually modulates tongue muscles 17

Considerations: combined with physical training enhances outcomes14. Can be used to

prime neurons, using as pre-training enhances outcomes.

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Motor Imagery/Mental Practice

Basic description: imagining planned movements requires areas of the brain to

activate that control movement preparation and execution14.

Parameters: in chronic CVA, imagery vs. placebo had significant effect on motor

outcome. Move non-affected side, then close eyes, imagine affected side doing

movement, then attempt to move affected side.

Clinical applications: can start early in rehab. Implemented

4 years post had significant effect on motor outcome14

Considerations: good in severe cases, can be combined

with other treatments. Lesions in L parietal/frontal may

have difficulty with this technique.

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Functional Electrical Stimulation

Basic description: Application of electrical stimulation over

key/affected muscle groups combined with task-oriented practice.

Parameters: Chronic Stroke: 3 hours per day, 5 days per week,

for 4 weeks 3. 120 minutes superior (compared to 30 and 60)4 .

Clinical applications: All levels of motor deficits, even just sensory

deficits (TENs). Can be carried over into home use. Emerging use in acute care.

Considerations: Cortical plasticity modulation continues up to several

hours after stimulation is removed13.

Music Therapy

Basic description: rhythmic auditory stim & musical motor

feedback

Parameters: implemented 1 week post stroke (long term plastic changes) lasting for 8 weeks-

combined music with other therapies.

Clinical applications: acute phase +, singing = greater word repeat and recall. Melodic

intonation- “Leads to remodeling of the right arcuate fasciculus (fiber bundle that combines the

anterior and posterior language area in the left hemisphere demonstrating that plasticity can be

induced in the contra-lateral homolog tract”. Gait rhythmicity, cadence, velocity, stride length.

Increased ROM, flexibility, + mood, increased frequency and quality of relationships14.

Considerations: improves executive function, emotional adjustment , attention, verbal

memory. Just listening activates pre-motor and motor pathways; with movement, improves

activation and connectivity of cortical cells. Multi-sensory. Great for providing feedback and

cueing motions14.

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Evidence Based Cognitive Therapy

ACRM Cognitive Rehab Manual- Attention Process Training,

N-back, Time Pressure Management, Predicting Performance,

Goal Plan Do Review, Spaced retrieval for memory,

Lighthouse Technique (neglect present in ~15% patients

20 months post- does not resolve on its own).

Oral Motor therapy- Frasier Method (errorless learning)

protocol for improving swallowing in aphasic patients without

compensating

ie: promoting return of skill through neuroplasticity-

repetitive sipping of clean water opposed to thickening liquids. 15

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•Technologies offer an amazing opportunity for

therapists to refine practice, enhance science, and

most importantly become even better at restoring

the function and quality of life of our clients.

- Lara Boyd PT, PhD

Promising New Research

Promising New Research

Robotics•Measured performance

•Feedback

•Intensive practice

•Normal movement

•Interactive

Virtual Reality – Based Therapies

•Multisensory, Multidimensional, Functional, Safe,

Individualized, Interactive, Motivating

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Promising New Research17

Cortical Stimulation

• Transcranial Magnetic Stimulation

• Transcranial Direct Current Stimulation

NeuroPharmacological Adjuncts

Brain Computer Interface

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Implications Without Intervention

Less social interactions- structural changes with isolation

Decreased life expectancy (physical sequelae)

Increased caregiver/society burden ($$$)

Learned non-use

Depression/Decreased QOL

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“Ideally, the rehab process is continuous until

the return of the individual to the family,

reintegration into the community, and

resumption of the patient’s professional

activities”.

-F.J. Carod-Artal

Discussion

•Questions

•Discussion

•Evaluation

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References

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2. Physical Exercise after Traumatic Brain Injury: Does the Timing and Type of Exercise Influence Cognitive Improvement? Lisa Kreber , et al.

Dept. of Psychology, Center for Neuroscience, University of Colorado, Boulder. Physical Exercise after Traumatic Brain Injury: Does the Timing

and Type of Exercise Influence Cognitive Improvement? http://www.colemaninstitute.org/Conferences/Coleman-2002/Boulder-

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11. Cramer, Stephen C. The EXCITE trial. A Major Step Forward for Restorative Therapies in Stroke

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References

Contact Information:clighthill@paterehab.com

ratkins@paterehab.com