It’s an exciting time in rehabilitation with a rapidly growing body of evidence from high quality research studies available to inform the specific clinical decisions we make every day. But it’s also an uncertain time in rehabilitation as we try to navigate a changing healthcare system and figure out how this new evidence applies to us.
Let’s take a look at four intervention principles emerging from the literature and think about how we can tweak our current practice to get more out of each minute of rehabilitation.
Use It or Lose It. Use It and Improve It.
Movement patterns and neural circuits degrade with lack of use and yet, are generally responsive to practice. If neural circuits are not actively engaged in task performance for an extended period of time, they “get rusty” and will begin to fade away. Improvements in sensory and motor performance brought about by skilled training are accompanied by profound plasticity within the cortex, and similar changes are hypothesized to occur in response to rehabilitation.
Bottom Line: Put the bar for rehab outcomes high enough so that the patient taps all possible movement, language, and cognitive resources available to them. Think about how to sustain improvements after discharge with activities that are challenging enough to prevent loss.
Complexity
Complexity of a task has shown to have a positive effect on structural plasticity within the brain. We can increase complexity of our treatments by varying the environment and context, adding to the motor load, adding a secondary task, and demanding multiple actions and longer sequences of activity. There’s evidence when treating patients recovering from a stroke that for learning new activities and motor behaviors, trying more difficult things earlier in the course of rehabilitation is associated with better outcomes.
Bottom Line: Present more complex activities earlier than you normally would. Tasks that the patient performs really well are probably not complex enough to be maximally therapeutic.
Task-Specific & Task-Related Training
Task training promotes skill development. There is evidence to suggest that both task-specific and task-related training is effective in generalizing to function. There is also evidence that straight plane or “out of context” exercise is more prevalent in practice than is task training.
Bottom Line: Select one or two tasks that you can modify for many different patients and have the required equipment already prepared. Consider alternate stair tap for balance, containers and lids for UE function and problem solving, or motor with swallow strategies to improve swallowing.
Intensity
Greater intensity is associated with improved motor performance. Similar to complexity, intensity refers to the level of challenge presented to the patient . Strategies to increase intensity include longer durations of effort and increasing the amount of work performed by adjusting force required, resistance, or rate of energy expenditure. Intensity involves pushing a patient past their self-selected effort.
Bottom Line: Think of one or two strategies that you can consistently use to increase intensity. Performing whatever task you are doing on a foam balance pad immediately increases the challenge to the patient. Be sure you are using sufficient resistance with exercise to get a strengthening effect. If the patient can perform more than 10 or 12 repetitions of an exercise in one set, think about increasing resistance (intensity).
Patty Scheets, PT, MHS, DPT, NCS – Director of Quality & Clinical Outcomes
Patty is a board certified specialist in neurologic physical therapy. She has been a clinical leader in a variety of practice settings and has a love of clinical research. Patty is leading initiatives related to the implementation of outcome measures, implementation of evidence-based practices or knowledge translation, and developing models of care that improve outcomes.
References:
Birkenmeier RL, Prager EM, Lang CE. Translating animal doses of task-specific training to people with chronic stroke in 1-hour therapy sessions: a proof of concept study. Neurorehabil Neural Repair. 2010; 24(7):620-635.
Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. 2008;51(1):S225-S239.
Lang CE, Macdonald JR, Reisman DS, et al. Observation of amounts of movement practice provided during stroke rehabilitation. Arch Phys Med Rehabil. 2009;90(10):1692-1698.
