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Clinical Implications. “Best Practice” In Neurorehabilitation. Factors In Recovery of Function. Mechanisms of Motor Learning. Transneuronal Lesion Effects. Recovery of Function. Stages of Recovery. What Rule Governs Synaptogenesis. Recovery Vs. Compensation. Recovery Of

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Presentation Transcript
slide1

Clinical

Implications

“Best Practice”

In Neurorehabilitation

Factors In

Recovery of Function

Mechanisms of

Motor Learning

Transneuronal

Lesion Effects

Recovery of Function

Stages of

Recovery

What Rule Governs

Synaptogenesis

Recovery

Vs.

Compensation

Recovery

Of

Function

Recovery

Theories

Map of Essential

Course Concepts

Fall 2006

DM McKeough

recovery of function
Recovery of Function
  • Mechanisms of motor learning
  • Recovery of function
  • Theories of the recovery of function
  • Transneuronal lesion effects
  • What rule governs synaptogenesis
  • Clinical Implications
  • Recovery vs compensation
  • Stages of recovery
  • Factors in recovery of function
  • Current “best practice” in neurorehabilitation

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mechanisms of motor learning

Jenkins et al, 1990

Mechanisms of Motor Learning

Motor learning causes increased differentiation in cortical representation

  • Training effects
    • In an accomplished pianist, hand representation in S1 and M1 is bigger than normal
  • Focal Hand Syndrome
    • Use dependent hand dysfunction caused by repetitive fast alternating finger movements resulting in loss of differential digital representation in M1 (Byl et al, 1996)

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recovery of function4
Recovery of Function
  • Do the same mechanisms that underlie motor learning also underlie recovery of function?
    • Looks like the answer is Yes

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theories of the recovery of function
Theories of theRecovery of Function
  • Resolution of diaschisis (edema)
  • Regenerative synaptogenesis (Wallerian re-generation-PNS)
  • Reactive synaptogenesis (Collateral sprouting - CNS)
  • Changes in cortical maps
  • Use of alternate pathways

Regenerative

synaptogenesis

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cellular response to injury
Cellular Response to Injury
  • What is diaschisis?
  • Temporary disruption of function produced by shock of damage to brain tissue (≈ spinal shock of the brain)
  • Includes loss of function of brain regions distant from primary site of injury
  • Possibly due to decreased blood flow, decreased metabolism or physiological disruption

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Regenerative Synaptogenesis

  • PNS Response to Injury
  • Begins 3-7 days post injury
  • Wallerian degeneration is the process whereby functional connections with target cells may be re-established following injury
  • Wallerian re-generation may permit recovery of lost function

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Theories of Recovery

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reactive synaptogenesis
Reactive Synaptogenesis
  • CNS response to injury
  • No re-establishing functional connections with target cells occurs, any recovery of function occurs via collateral sprouting from intact neurons &/or reorganization (intact systems assume the lost function, neuroplasticity)

collateral sprouting +/or reorganization = neuroplasticity

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cortical reorganization 1 2
Cortical Reorganization 1/2
  • What mechanisms underlie the recovery of function?
  • Changes in cortical maps
    • Following peripheral injuries: (Amputation)
      • Intact adjacent areas of the cortex expand into quiet areas (due to unmasking of silent synapses)
    • Following central lesions: (Stroke)
      • Same
    • Following injury cortical mapping is responsive to training
    • Changes are progressive and reversible
    • Once the task was learned, mapping changes persist long-term

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cortical reorganization 2 2

Taub et al 1998

Cortical Reorganization 2/2

Use-Dependent Cortical Reorganization After Brain Injury

Mechanisms of effectiveness of Constraint-Induced Movement Therapy(CIMT)

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alternate pathways
Alternate Pathways
  • What mechanisms underlie the recovery of function?
  • Ipsilateral motor tracts take over

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transneuronal lesion effects

Retrograde

Orthograde

Transneuronal Lesion Effects
  • Transneuronal (Transsynaptic) lesion effects
    • Orthograde:
      • Muscular atrophy
      • Denervation hypersensitivity (spasticity)
    • Retrograde:
      • Synaptic retraction
      • Atrophy of presynaptic cell
      • Glial ensheathment

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synaptogenesis
Synaptogenesis
  • What rule seem to govern synaptogenesis?
  • Use dependent competition such that if one area becomes silent, adjacent areas can re-program its use

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clinical implications
Clinical Implications
  • How is this information useful in the clinic?
  • Following injury cortical maps show:
    • Short-term changes (due to unmasking)
    • Long-term changes (due to adjacent areas take over the silent area)
  • Cortical mapping (re-mapping) is experientially dependent and requires willful intention

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recovery vs compensation
Recovery vs Compensation
  • Recovery is achieving function through original processes, while compensation is achieving function through alternative processes
  • Should intervention strategies change for the two goals?

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stages of recovery
Stages of Recovery
  • Spontaneous recovery
    • Recovery in the absence of intervention
  • Forced recovery
    • Achieved through specific intervention designed to affect neural mechanisms

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factors contributing to recovery of function
Factors Contributing to Recovery of Function
  • Age
  • Characteristics of the lesion
  • Effect of Experience
  • Effect of Pharmacology
  • Effect of Training

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factors contributing to recovery of function18
Factors Contributing to Recovery of Function
  • Age
    • The brain reacts differently to injury at different stages of development
    • In general, the younger the age at the time of injury the better the outcome
  • Characteristics of the lesion
    • The smaller the lesion: smaller primary impairment
    • The longer it takes to develop: greater opportunity for collateral circulation and substitution
    • The better the outcome

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factors contributing to recovery of function19
Factors Contributing to Recovery of Function
  • Effect of Experience
    • Enriched environment produces increased brain weight, dendritic branching, and enzyme activity
    • Postoperative enrichment is effective but does not allow the same extent of recovery as preoperative enrichment (Held 1985)
    • If environmental enrichment is to affect recovery of function, it must incorporate active participation of the patient for full recovery to occur (Stein 1995)

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factors contributing to recovery of function20
Factors Contributing to Recovery of Function
  • Effect of Pharmacology
    • Amphetamine enhances the effects of neurotransmitters
      • Amphetamine plus PT produced significant improvement in motor performance on the Fugl-Meyer test (Crisostomo 1988)
    • GABA has harmful effects on recovery of function after brain damage
    • Cholinergic agents facilitate recovery of function after brain damage (vanWoerkom 1982)
    • Free radicals destroy the lipid membrane of the cell
    • Drugs used to treat common comorbidities (antihypertensives and sedatives) have deleterious effects on recovery of motor and language functions after stroke (Goldstein 1995)

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factors contributing to recovery of function21
Factors Contributing to Recovery of Function
  • Effect of Training
    • Training has its greatest effect when performed as soon after the injury as possible
    • It is not likely that any single training approach will be as effective as a combination of interventions
    • Treatment strategies will be most effective when carefully considering the patient’s history, health status, age, and experience

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best practice
“Best Practice”
  • According to research results the current “best practice” approach to neurological rehabilitation is:
    • task-specific training
    • that requires willful intention
    • performed in an enriched environment
    • with facilitatory pharmacology
    • using a variety of treatment approaches
    • that soon after the injury and
    • is tailored to the individual patient’s history, health status, age, and experience
    • involving both physical and mental practice

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the end

The End

© DM McKeough 2006

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