Presented by:
Megan Setlock, MS, OTR/L; [email protected]
Cydne Cupka, COTA/L, CBIS; [email protected]
 Disclosure

Neither the presenters nor Sheltering Arms
have financial interests in the technologies,
companies, or products discussed in this
presentation.
 For
Presentation Handout:
www.shelteringarms.com/vota2014
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 The
participant will be able to identify
neuroplasticity principles and the recommended
number of repetitions associated with cortical
reorganization.
 The participant will be able to discuss current
research trends regarding number of repetitions
achieved in traditional therapy on average in
inpatient rehabilitation settings.
 The participant will be able to identify the
benefits of advanced technologies through the
use of a Clinical Practice Guideline to address
repetitions required for neurologic recovery.
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 “The
various ways in which the nervous
system can change its function as a result of
training, or in response to injury” (Henson &
Keogh, 2010, p. E54).
 “Neural
plasticity is believed to be the basis
for both learning in the intact brain and
relearning in the damaged brain that occurs
through physical rehabilitation” (Kleim &
Jones, 2008, p. S225).
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
Extrinsic factors:

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
Motor learning
Motor relearning
Electrical stimulation
Pharmacological stimulation
Behavior
•
Intrinsic factors:

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
Genotype
Stage of development
Age
Sex
Location of injury
Severity of injury
Time post injury
Prior experience
(Plowman & Kleim, 2010)
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 Use it or lose
 Specificity
 Time
 Intensity
it
 Use it and improve
 Repetition
 Saliency
 Age
 Transference
 Interference
it
(Kleim & Jones, 2008)
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 Studied
the effect that constraint-induced
movement therapy (CIMT) paired with
rehabilitation has on rats s/p an intracerebral
hemorrhage (ICH)



Completed with 67 rats
Divided into four study groups
Behavioral training and recovery assessments
completed
(DeBow, Davies, Clarke, & Colbourne, 2003)
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 Subjects
that received a combination of CIMT and
rehabilitation illustrated:


Improved motor recovery
Smaller volume of tissue loss
(DeBow, Davies, Clarke, & Colbourne, 2003)
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 Study
to determine the effect that skilled
learning vs. strength training had on cortical
reorganization



Completed with 24 adult rats
Divided into three study groups
Movement analysis and electrophysiological
mapping completed to gather data
(Remple, Bruneau, VandenBerg, Goertzen, & Kliem, 2001)
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 “Power
Reaching and Control Reaching animals
exhibited a significant increase in the
proportion of motor cortex occupied by distal
forelimb movement representations
(wrist/digit) and a decrease in the proportion
of proximal representations (elbow/shoulder)”
(Remple, Bruneau, VandenBerg, Goertzen, &
Kliem, 2001, p. 133).
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 Study
to examine the functional outcomes and
neuromorphological changes that occur after
receiving therapy 5, 14, and 30 days post stroke

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Conducted with 40 rats
Five behavior assessments were completed
Neuroanatomical procedures utilized to gather
data
(Biernaskie, Chernenko, & Corbett, 2004)
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 Rehabilitation
5 days post stroke had marked
improvements on the behavioral assessments as
well as improved an overall improvement of the
number and length of dendritic branches
(Biernaskie, Chernenko, & Corbett, 2004)
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 Studied
the effect of highly repetitive skilled vs
unskilled tasks on the overall learning process,
synapse number, and brain function in the
mammalian brain

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
Completed with 12 rats
Divided into two groups
400 repetitions of reaches each session
(Kleim, Barbay, et al., 2002)
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 Engagement
in highly repetitive skilled
reaching tasks:

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Produces more successful reaches overall
Contribute to significantly more movement
representations within the caudal forelimb
area (CFA) and significantly thicker cortices
within the CFA
Increase number of synapses/neurons within
the CFA
(Kleim, Barbay, et al., 2002)
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 Two


part study:
1- “To determine the effect of massed practice (MP)
verses massed practice combined with
somatosensory stimulation (MP+SS) on cortical
plasticity and function in persons with incomplete
tetraplegia” (Beekhuizen & Field-Fote, 2005, p. 33).
2- Discover if greater improvement will occur in
massed practice when combined with
somatosensory stimulation
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

Completed with 10 human subjects
Divided into two groups
Completed two hour sessions, five days/week, three weeks
total
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 This
study indicated that it is possible to
achieve additional functional gains even in
the chronic stages of injury
 Results indicated that subjects in MP+SS
group demonstrated improvements in pinch,
grip, and the Wolfe Motor Functional Test
 Both groups demonstrated improvement in
the Jebson Hand Function Test
(Beekhuizen & Field-Forte, 2005)
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 Study
on how many repetitions could be done in
one hour and assess the benefit of highly
repetitive training
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13 human subjects diagnosed with chronic stroke
Baseline assessments utilized
Highly repetitive task-specific training
(Birkenmeier, Prager, & Lang, 2010)
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 Results
indicated it is feasible to achieve
hundreds of task-specific upper extremity
repetitions in one hour sessions

Average of 322 repetitions per session
 Improvement
in outcomes noted
(Birkenmeier, Prager, & Lang, 2010)
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 Researched
the relationship between
engagement in skilled motor tasks and the
plasticity of the sensorimotor cortex


Competed with 26 rats
Included reaching and grasping training
 Results
indicated an increase in synapse
strength was noted after continual
stimulation for a prolonged period of time
(Monfils & Teskey, 2004)
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 Study
to investigate the possibility of delivering
a highly repetitive, task-specific, individualized
treatment training
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15 human subjects
Inpatient rehab setting
Constraint induced movement therapy training
 Results
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Average of 289 repetitions per session
Forty-seven minutes of active training was achieved
per session
Functional improvements noted
(Waddell, Birkenmeier, Moore, Hornby & Lang, 2014)
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 Study
to assess the effectiveness and use of the
Hand Dance Pro gaming system with subjects s/p
stroke greater than six months with hemiparesis
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9 human subjects
Outcome measures utilized
Eight intervention sessions over a six week period
(Combs, Finley, et al., 2012)
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 The
use of this gaming system is feasible and
resulted in improvement in UE movement in
chronic stroke individuals
(Combs, Finley, et al., 2012)
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 Study
to determine if moving quickly has an
effect on the performance of an impaired UE
during a functional task
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27 human subjects
Outcome measure assessments utilized
Trails completed for preferred speed
Additional trails completed of same task at a fastest
possible speed
(Dejong, Schaefer, & Lang, 2011)
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 “People
with mild to moderate post stroke
hemiparesis are able to increase their
movement speed on request, and when they
do, movement quality is improved. Reach
paths are straighter, finger movements are
more efficient, and fingers open wider”
(Dejong, Schaefer, & Lang, 2011, p. 368).
 Improvement was shown for both groups
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INTENSITY
VOLUME
DOSAGE
DURATION
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FREQUENCY
A
study in 2009 reported the average length of
stay for a patient diagnosed with a CVA was 14
days in an inpatient rehabilitation setting
 In addition, patients did not receive full “3 hours”
of intensive therapy a day due to time spent
setting up treatment, transportation, and medical
needs
(Krakauer, Carmichael, Corbett, & Wittenberg, 2012)
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 Additional
studies indicated that task-specific
training occurs in only about half of therapy
sessions focused on the upper extremity
(Lang, Reisman, et al., 2009; Bernhardt, Chan, Nicola, & Collier, 2007;
Harris, Eng, et al., 2009)
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 Robotics
 Arm
Based Spring-Assisted Therapy
 Forearm Based Spring-Assisted Therapy
 Hand Based Spring-Assisted Therapy
 Arm Based Functional Electrical Stimulation
 Hand Based Functional Electrical Stimulation
 Virtual Reality
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REO-Go
Armeo Power
http://www.motorika.com/?categoryId=65107
http://www.hocoma.com/products/armeo/armeopower/
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SaeboFlex
ArmeoSpring
SaeboMAS
http://www.saebo.com/products/saeboflex/
http://www.hocoma.com/products/armeo/armeospring/
http://www.saebo.com/products/saebomas/
Property of Sheltering Arms. Do not use or alter without permission.
Bioness H200
RT300
http://www.bioness.com/H200_for_Hand_Paralysis.php
http://www.restorative-therapies.com/products
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iPad apps, e.g. Puzzle Me”
Wii Sports Golf
Medical VR
Center,
“Virtual Cave”
Armeo Boom
http://itunes.apple.com/us/app/puzzle-me-!!!/id393499831?mt=8
http://www.nintendo.com/games/detail/1OTtO06SP7M52gi5m8pD6CnahbW8CzxE
http://www.mvrc.pitt.edu/facility_balance.html
http://www.hocoma.com/products/armeo/armeoboom/features-functions/
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
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Benefits
Evidence-based
Concrete stimuli
Specific to desired tasks
Repetitive and intense
Multi-sensory experience
Modifiable
Safe errors
Interactive
Provide feedback
Provide objective data
Capability to guide and
measure improvements
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
Limitations
Cognitive requirement
Visual component
Contractures/Tone
Pain if over-utilized
Focus primarily on distal
recovery
Technological error
Cost and accessibility
Size of workspace
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How is it implemented?
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
Utilizes advanced technology to better promote
neuroplasticity principles

High repetitions - High Intensity – Increased
Treatment Time


Task Specific Training


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Purposeful reaching/grasping/targeting facilitates better
results than rote exercise or training of isolated movements
Goal oriented treatment gives patients a reason to move
Novelty – Cognitive Challenge


Advanced technology can provide significantly more
repetitions than the therapist without getting tired!
Advanced technology treatment is more exciting and
stimulating than towel slides and passive range!
Unilateral training– Multisensory treatment

Increased awareness and focus on the affected extremity
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Severe
Impairment
Moderate
Impairment
Mild
Impairment
REO
Bioness H200)
RT 300
SaeboMAS
SaeboFLEX
ARMEO Spring
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 Patient




Information:
Diagnosis: Right Pontomedullary ischemic CVA
8/6/14
54 Year old female
Admitted to inpatient rehabilitation hospital on
August 8th, 2014
Social Environment: Married, Worked Full time
 Past
Medical History: Significant for high blood
pressure, obesity
 Prior
Level Of Function: Independent with all self
care, IADLs
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Admission Functional Independence Measures
Eating- Supervision
Transfers- Maximal Assist
Grooming- Minimal Assistance
Toileting- Moderate Assist
Upper Body Dressing- Moderate
Assist
Tub Transfers- Dependent
(Did not occur due to safety)
Lower Body Dressing- Dependent
Memory- Minimal Assist
Bathing- Maximal Assist
Problem Solving- Minimal Assist
Toilet Transfers- Moderate Assist
Social Interaction- Supervision
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Admission Outcome Measures
Assessment
Right
Left
Grip
40 PSI
0 PSI
9 Hole Peg Test
47 Pegs
999 Pegs
Box and Block
42 Blocks
0 Blocks
Fugl Meyer
66 Points
9 Points
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 Plan

of Care:
Occupational Therapy focus on high repetitions
with the use of advanced technology
 Reo
 Bioness
 Armeo
 SAEBO MAS
 SAEBO Flex
 Weight bearing
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Functional Independence Measures
Admission FIMS
Discharge FIMS
Eating
Supervision
Supervision
Grooming
Minimal Assist
Modified Independent
Upper Body Dressing
Moderate Assist
Modified Independent
Lower Body Dressing
Dependent
Supervision
Bathing
Maximal Assist
Modified Independent
Tub Transfers
Dependent
Modified Independent
Toilet Transfers
Moderate Assist
Modified Independent
Transfers
Maximal Assist
Modified Independent
Toileting
Moderate Assist
Modified Independent
Memory
Minimal Assist
Independent
Problem Solving
Minimal Assist
Independent
Social Interaction
Supervision
Independent
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Outcome Measures
Admission
Discharge
Assessment
Right
Left
Right
Left
Grip
40 PSI
0 PSI
66 PSI
15.6 PSI
9 Hole Peg Test
47 Sec
999 Sec
36.3 Sec
126 Sec
Box and Blocks
42 Blocks
0 Blocks
54 Blocks
26 Blocks
Fugl Meyer
66 Points
9 Points
66 Points
42 Points
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 Lack

of repetition research in general
Abundance of animal vs human research
 Translating

results of animal research
Utilization of clinical judgment/inferences with
current research
 Magic
number of repetitions still unknown
 Lack of research with subjects who have fully
flaccid UEs
 Sheltering Arms current research project
Property of Sheltering Arms. Do not use or alter without permission.
Property of Sheltering Arms. Do not use or alter without permission.

Beekhuizen, K. S., & Field-Fote, E. C. (2005). Massed practice versus massed practice with stimulation:
Effects on upper extremity function and cortical plasticity in individuals with incomplete cervical spinal
cord injury. Neurorehabilitation and Neural Repair, 19, 33-45.

Bernhardt, J., Chan, J., Nicola, L., & Collier, J. M. (2007). Little therapy, little physical activity: Rehabilitation
within the first 14 days of organized stroke unit care. Journal of Rehabilitation Medicine, 39, 43-48.
http://dx.doi.org/10.2340/16501977-0013

Biernaskie, J., Chernenko, G., & Corbett, D. (2004, Feburary 4). Efficacy of rehabilitative experience
declines with time after focal ischemic brain injury. Journal of Neuroscience, 24(5), 1245-1254.

Birkenmeier, R. L., Prager, E. M., & Lang, C. E. (2010, September). Translating animal doses of task-specific
training to people with chronic stroke in 1-hour therapy sessions: A proof-of-concept study.
Neurorehabilitation & Neural Repair, 24(7), 620-635. doi: 10.1177/1545968310361957

Combs, S. A., Finley, M. A., Henss, M., Himmler, S., Lapota, K., & Stillwell, D. (2012). Effects of a repetitive
gaming intervention on upper extremity impairments and function in persons with chronic stroke: A
preliminary study. Disability and Rehabilitation, 34(15), 1291-1298. doi: 10.3109/09638288.2011.641660

Debow, S. B., Davies, M. L.A., Clarke, H. L., & Colbourne, F. (2003, March 20). Constraint-induced
movement therapy and rehabilitation exercises lesson motor deficits and volume of brain injury after
striatal hemorrhagic stroke in rats. Journal of the American Heart Association, 34, 1021-1026. doi:
10.1161/01.STR.0000063374.89732.9F

DeJong, S. L., Schaefer, S. Y.,& Lang, C. E. (2011,December 2). Need for speed: Better movement quality
during faster task performance after stroke. Neurorehabilitation & Neural Repair, 26(4), 362-373. doi:
10.1177/1545968311425926

Hension, J. W., & Keogh, B. P. (2010). Plasticity: Teaching the old brain new tricks. Neurology, 74, e53-e55.
doi:10.1212/WNL.0b013e3181d7b472
Property of Sheltering Arms. Do not use or alter without permission.

Harris, J. E., Eng, J. J., Miller, W. C., & Dawson, A. S. (2009). A self-administered Graded Repetitive Arm
Supplementary Program (GRASP) improves arm function during impatient stroke rehabilitation: A multi-site
randomized controlled trial. Stroke, 40, 2123–2128. http://dx.doi.org/10.1161/STROKEAHA. 108.544585

Kleim, J. A., Barbay, S., Cooper, N. R., Hogg, T. M., Reidel, C. N., Remple, M. S., & Nudo, R. J. (2002).
Motor learning-dependent synaptogenesis is localized to functionally reorganized motor cortex.
Neurobiology of Learning and Memory, 7, 63-77. doi: 10.1006/nlme.2000.4004

Kleim, J. A., & Jones, T. A. (2008, February). Principles of experience-dependent neural plasticity:
Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research, 51,
S225-S239.

Krakauer, J. W., Carmichael, S. T., Corbett, D., & Wittenberg, G. F. (2012). Getting neurorehabilitation
right: What can be learned from animal models? Neurorehabilitation and Neural Repair, 26(8), 923-931.

Lang, C. E., Macdonald, J. R., Reisman, D. S., Boyd, L., Jacobson, Kimberley, T., Schindler-Ivens, S. M., . . .
Scheets, P. L. (2009). Observation of amounts of movement practice provided during stroke rehabilitation.
Archives of Physical Medicine and Rehabilitation, 90, 1692-1698.
http://dx.doi.org/10.1016/j.apmr.2009.04.005

Monfils, M. H., & Teskey, G. C. (2004). Skilled-learning-induced potentiation in rat sensorimotor cortex: A
transient form of behavioural long-term potentiation. Neuroscience, 125, 329-336. doi:
10.1016/j.neuroscience.2004.01.048
Property of Sheltering Arms. Do not use or alter without permission.

Plowman, E. K., & Kleim, J. A. (2010). Motor cortex reorganization across the lifespan. Journal of
Communication Disorders, 43, 286-294.

Remple, M. S., Bruneau, R. M., VandenBerg, P. M., Goertzen, C., & Kliem, J. A. (2001). Sensitivity of cortical
movement representations to motor experience: Evidence that skilled learning but not strength training
induces cortical reorganization. Behavioral Brain Research, 123, 133-141.

Waddell, K. J., Birkenmeier, R. L., Moore, J. L., Hornby, T. G., & Lang, C. E. (2014). Feasibility of highrepetition, task-specific training for individuals with upper-extremity paresis. American Journal of
Occupational Therapy, 68(4), 444-453.
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