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What is neuroplasticity?

  • Ability of the nervous system to change as circumstances require. 
    • Instrinsic and extrinsic stimuli trigger reorganization of structure, function and connections
    • Can occur at any level of the nervous system 


Explaining Cortical mapping

Dermatomes on skin have cortical receptive fields that slightly overlap - the more they overlap the more fine the tactile discrimination


Functional reorganization of the cortex for the hand can be long lasting due to:

  • -Changed sensory experience
  • -Performance of the hand
  • -Local peripheral nerve injury
  • -Separation of syndactylies (fingers)
  • -UE slings


2 types of CNS plasticity

  • 1. Synaptic plasticity
    • -Increased/decreased sensitivity
    • -Increase/decrease in actual number
  • 2. Cortical plasticity - size, synapses etc.
  • CHANGES ARE ACTIVITY DEPENDENT (CPM won't work - need active component)


Key points about the reorganization of motor cortex

  • -Expands into other areas
  • -Reversible


How to increase neuroplasticity

  • 1. Must be active - passive stimulation doesn't work.
  • 2. Attention to task important for optimal environment.


Not all neuroplasticity is positive


Tactile function can worsen with certain forms of sensory stimulation (vibration for construction workers)
-Dystonia (form of writer's cramp) - such a low threshold that it's easy to activate


Who is Edward Taub and what did he find?

  • Edward Taub - one of founders of neuroplasticity
  • Found increased cortical representation of the hand of string musicians.


How to make CIMT effective


  • 1. Feedback
  • 2. Active
  • 3. Reward them and make it achievable
  • 4. Self efficacy - let them know why it's important - what goal are you working towards that they want to achieve?


CIMT: Shaping

How you set up the enviornment

  • 1. Explicit feedback to smallest improvement (Knowledge of results)
  • 2. Lots of positive feedback/rewards, de-emphasize negative
  • 3. Relate shaping task to functional task
  • 4. Can use assisted movement with lower functioning patient


Task Practice

  • 1. No explicit training
  • 2. Functional tasks used
  • 3. Limited feedback provided
  • 4. GOAL: Use of limb

NOT as effective as shaping approach


Benefits of CIMT

  • 1. Overcoming learned nondisuse - reverse mindset of dysfunction
  • 2. Cortical reorganization can occur with focused training


When to start aggressive therapy?

  • Don't want to overstress brain as it is healing (first 1-2 weeks post stroke)
  • --Basically like overtraining.


Optimizing functional carryovers: Blocked design vs. Random design

Blocked: Initial performance better but worse retention.

Random exercise and trial and error = better retention and learning (performance initially worse)


Initial inclusion criteria for Modified CI Therapy

  • Some finger and wrist movements
  • 10° wrist extension
  • 10° thumb abduction
  • 10° extension of 2 digits
  • 50% all stroke patients met this criteria


CIMT summary

Inclusion criteria: cognition intact, some active wrist and finger extension 

  • Massed practice- 5-6 hrs/day for weeks or less intense, longer duration for months 
  • Restrained uninvolved UE 5-6 hours/day minimum
  • Active, repeated, task-specific practice is critical
  • Significant feedback and encouragement
  • Consider massed practice bilaterally
  • Avoid stressing the CNS too early in acute care--- intense therapy is detrimental to the brain because the brain is still healing 
  • 1 year follow up shows no difference with or without the use of a mitt on unaffected UE


Treatment of focal hand dystonia

Overuse causes cortical smudges
-Minimal repeated practice


Mirror Therapy

using visual input instead of somatosensory input
Movement of intact extremity looks like bilateral movement "trick" brain into activating cortical neurons?


Neurological basis of mirror therapy

Mirror-Neuron system

  • Cortical neurons that are activated while moving can also be activated by watching movement


Areas of brain activated by Mirror Therapy

  • 1. Superior temporal gyrus
  • 2. Pre-motor cortex
  • 3. Ipsilateral primary motor cortex
  • 4. Integraton with attention (percuneus area)
  • 5. Mirror neuron system may connect perceptual and motor areas


Specialized electrical stimulation devices for muscle movement

  • Neuro-prostheses - can assist via electrical stimulation to provide many reps.
  • 1. Bioness - synchronize electrical pulses to stimulate correct muscles during gait.
  • 2. Walkaide - just on fibular nerve


Necessities for Gait

  • 1. Biomechanics
    • -Appropriate ROM
    • -Appropriate Timing
  • 2. Neuromuscular control
    • -Cortical level - initiate gait
    • -SC level - SC generator yielding automaticity and reproducibility
    • -strength, balance, coordination
  • 3. Cardiovascular stamina


Idea behind Body Weight Support Treadmill Training (BWSTT)

Initiate gait at cortical level and then becomes automatic


Some parts of the neuromotor pathways affecting gait that can malfunction and lead to abnormalities


  • Higher centers - dyscontrol over spinal cord outflow
    • tone problems, difficulty initiating movement, decreased strength
  • Basal ganglia - modulation of movement
  • Cerebellum - balance and coordination
  • SC lesion - weakness, tone issues


Central Pattern Generators


  • Spinal processes capable of producing rhythmic control of one limb
  • -With or without descending control (cortical input)
  • -Adaptable/plastic with specific tasks
  • (based on Sherrington in 1910)


Dobkin research on CPGs

  • EMG activity during passive training in clinically complete SCI patients.
  • -Modulated by limb loading
  • -Not related to muscle stretch


Treatment Rationale for BWSTT

  • Biomechanical environment
  • Rhythmic coordinated movement
  • Stimulate CPG
  • Reach brainstem with partially intact pathways to activate higher centers
  • Postural stability
  • Goal oriented
  • Task-specific
  • Intensive



  • Mid-stance limb-loading
  • Terminal stance: hip extension


BWSTT Clinical Rationale

  • -Gait is complete & task specific
  • -Gait pattern must be practiced in functional context
  • -Reduction in degree of difficulty results in better participation and outcome
  • -Gradual increase in demand for WB and balance to wean off
  • -PT free to cue/facilitate patterns


BWSTT allows PT to...

  • -Control WB
  • -Manually assist limb
  • -Control postural alignment
  • -Adjust for unilateral weakness
  • -Facilitate proper gait pattern
  • -Work on symmetry, weight shift
  • -Facilitate hip extension
  • -Begin earlier gait training
  • -Observe/evaluate
  • -Teach AD
  • -Work on vestibular response


Training parameters of BWSTT

  • -Speed from .1mph
  • -Support 40% to eventually 0%
  • -Assist max to min


PNF gait evaluation

Analyze performance→ Prioritize strengths and weaknesses→ simple interventions→ re-assess the problems→ more advanced interventions→ re-assess the problem→ starts again


Pelvic Components during typical gait

  • Very Initial Swing
    • Posterior elevation + anterior elevation= co-contraction
  • Initial Swing
    • Anterior Elevation- concentric
  • Late Swing/Initial Contact
    • Anterior Depression
    • Use of eccentric posterior elevators 
  • Mid-stance to Toe Off
    • Posterior Depression


Resisted Gait Activities

    • Eccentric posterior elevator muscle activity to allow pelvis to lower into anterior depression at end of swing and heel strike
    • Isometric holding posterior elevation at very end of stance/initial swing transition
    • resisted posterior elevation
    • select one part of cycle (weight transference, push-off and swing) and repeatedly resist it thru dowel.


Hierarchical Theory 

Recovery of function occurs in specific sequence- simple tasks before complex ones

(Brunnstrom, Rood, Bobath)


Generalized Motor Program Theory

Schmidt’s Schema Theory

We have patterns for certain movements like walking, brushing teeth


Neuronal Group Theory

  • Groups of neurons activated in response to task conditions.
  • Brain initiates movement but then don't need it any more after that.

    • Ex. Such as when start walking just keep going w/out thinking about it, unless something goes wrong like a trip


Dynamic Systems Theory

  • Change occurs because one control parameter or variable, reaches a critical value, which causes a change in the entire system.

  • Constraint (such as speed) control parameter
When variables change motor output changes
Ex of horses 


Perception Action Theory

Gibson (1996)

Take home - train in actual environment with actual implements needed for the task


Degrees of Freedom


  • multiple ways for humans or animals to perform a movement in order to achieve the same goal.


Dynamic Pattern Theory

Kelso (1987)

  • Ability to shift from one coordinated pattern of movement (attractor state) to another according to the conditions of the task, environment and performer
  • Order parameter is the type of coordinated movement needed for the task 
  • Control parameter is the force or desire that creates the phase shift



Primary Goals of NDT

  • Inhibit poor, non-functional patterns of movement 
  • Train more complex, functional patterns of POSTURE (not talked about in brunstrom) and MOVEMENT 
  • Ensure that the patient is an active learner


Implicit vs. Explicit Feedback

Implicit - characteristics of task (foot hitting cone, visual etc.) (environmental driven)
Explicit - Usually language based.

Children need more feedback


Augmented feedback achieved the following:

Potential problem?

  • Improves or produces motivation
  • Provides information on errors
  • Directs the learners attention towards a movement  or goal

Creates dependency (problems with withdrawal or feedback)


Feedback: Knowledge of results vs. knowledge of performance

    • -Verbal
    • -Augmented
    • -Provided after movement
  • DIFFERENCES (Results vs. Performance)
    • Info about goal outcome vs. Info about movement process
    • Provided as a score vs. kinematic info
    • Lab research vs. Everyday activieis


Non-Declarative Memory


Explicit vs. Implicit Learning based on lesion site


Motor control integration: Problems related to disturbed perception

  • 1. Difficult to describe
  • 2. Must be observed
  • 3. Bilateral loss of discriminative sense in some modalities
  • 4. Dressing - non motor aspects


How to maximize Motor learning

  • 1. Practice
  • 2. Repeated attempts to perform beyond capabilities
  • 3. Re-learning behaviors (not new way to do them)
  • 4. PT as facilitator
  • 5. Structure of the session (order and amount of practice)


Motor control integration: Common problems associated with disturbed perception

  • 1. Hypertonicity - can be result of inadequate sensory info
  • 2. Adopting end range joint position
  • 3. Hyperactivity and inordinately quick responses to commands
  • 4. Pressing too hard against support surfaces
  • 5. Too much effort for simple tasks
  • 6. Inability to perform task despite adequate strength
  • 7. Inability to remember instructions
  • 8. Urinary incontinence
  • 9. Poor carryover
  • 10. Loss of initiative
  • 11. Aphasia


Task Analysis answer what questions? 

  • What joint movements are required to perform task? (Think UE, LE, and trunk)
  • Which muscles are working, and what types of contractions are being performed?
  • Where do they need assistance?
    • How can you use guiding principle to provide it?
    • How can you break the task down if needed?


Analysis leading to appropriate interventions:

  1. Look at any movement pattern
  2. Evaluate its components
  3. Identify what is missing
  4.  Incorporate tx strategies that help the client achieve the desired function outcome


NDT vs. PNF (hand placement, contact, pressure applied, task)

  • NDT | PNF
  • Hand open | Closed
  • Contact on muscle belly | Bony prominence
  • Pressure causing activation of muscles (as light as possible) | assist -> resist groups of muscles in pattern
  • Task: WB | WS
  • BOTH get in good alignment first


Closed chain WB exercises promotes:

  • Proprioception
  • Sensory processes and postural support
  • Potential to initiate automatic movement 


NDT Upper Extremity treatment sequence

  • 1. Alignment
  • 2. Weight bearing - body on arm
  • 3. Weight bearing - arm on body
    • -Isometric
    • -Eccentric
    • -Concentric
  • 4. Contralateral to ipsilateral movements


NDT Upper Extremity treatment sequence example: ALIGNMENT

  • Feet hip width apart, at 90/90 - balance between abs and extensors
  • Place uninvolved arm on upper thigh or edge of mat - DO NOT place it further forward or higher than involved
  • Involved arm: Scapula against thorax in slight abduction and upward rotation
  • Shoulder: humerus slightly flexed, abducted and ER
  • Elbow: 90° to complete extension (hand below elbow)
  • Forearm - pronated
  • Wrist - neutral
  • Hand - open on WB surface (preserve arch)


NDT Upper Extremity treatment sequence example: WB SEQUENCE

  • -Progress from isometric to eccentric to concentric
  • -Incorporate head and eye movements
  • -Unilateral to bilateral
  • -Stable surface to less stable and progressive humeral elevation
  • -Forward WBing to posterior WBing
  • -Progress toward more upright postures, vary WBing surfaces / step standing at dif heights


What "key points of control" can be used to promote extension of the trunk?

Scapula and tripceps

Thumb on tricep


NDT: Opening High-Toned hand: Points of contact

  • 1. Borders of the hand
    • -hypothenar eminence (shaft of 5th MC)
    • -Heads of Metacarpals
    • -Shaft of 1st Metacarpals 
  • 2. Palmar surfaces of fingers
  • 3. Any place on dorsum except thenar web space
  • AVOID: center of palm. thenar eminence and web


NDT: Opening High-Toned hand: principles

  • Open the hand from distal to proximal
  • Extend the wrist last, but get and maintain neutral (or more neutral wrist deviation throughout)
  • The thumb out of the palm into radial deviation is key- movement from the CMC joint not hyperextension at the MCP joint
  • Spread between the MC- abduction is key
  • Avoid MCP hyperextension a little short of neutral, especially of 2nd and 3rd fingers is fine


Common gait impairments in stroke

  • 1. Decreased hip extension at end of stance
  • 2. Decreased hip flexion in mid-swing
  • 3. Decreased knee flexion at toe off and mid-swing
  • 4. Decreased DF at foot contact and during stance associated with hyperextended knee
  • 5. Increased knee flexion at foot contact


NDT Sequence in standing

  • 1. Bilateral knee bends
  • 2. Shift to involved LE with "release" of uninvolved knee
  • 3. Shift to involved LE, toe in/out with uninvolved
  • 4. Shift to involved LE, step forward with uninvolved