Therapeutic Benefits from
Aggressive, Recovery Focused,
Physical Therapy Program
Bill Thornton MPT
Clinical Director
Level Eleven Physical Therapy
Objectives
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Review General TBI Statistics
Review TBI-Related Disabilities
Explain/Define Neuralplasticity
Explain/Define Aggressive Recovery
Focused Therapy
• Explain/Define Secondary Benefits of
Aggressive Therapy
TBI Statistics
• Leading cause of death among children and
young adults (highest frequency = 15-25 y/0)
• 5.3 million individuals with TBI-related disability
in US
• Two thirds of individuals with TBI are below the
age of 36
• 78% of the above are male
• Yearly incidence is 1/2000
Morris et al 2006
Hoofien et al 2001
TBI Statistics
• 1.5 – 2 million TBI per year in US
• 70,000 – 90,000 of these individuals incur a TBI
that results in long-term loss of physical and
mental function
• Average life expectancy of an individual with a
TBI is 50 years
• There are very few studies that have looked at
the long-term sequelae associated with TBI
Hoofien et al 2001
TBI Related Disabilities
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Impaired use of extremities
Impaired speech
Impaired cognition
Impaired vocational capabilities
Costs Comparisons
Condition
Incidence
Deaths
Cost
Brain injury
2 million
100,000
$25 billion
Stroke
2.6 million
145,000
$25 billion
SCI
10,000
unknown
$8 billion
Cancer
1.1 million
510,000
$104 billion
AIDS
50,000
26,000
$15 billion
http://www.headinjury.com/coststbi.htm
Intensive Recovery Focused
Rehabilitation Philosophy
• Anticipate/promote recovery and prevent
learned non-use/substituted patterns
• Bombard the CNS with sensory (afferent)
information (when appropriate)
• Couple the entire body when ever possible
Intensive Recovery Focused
Rehabilitation Philosophy
• Continually seek novel application of both
new and current rehabilitation paradigms to
stimulate, irritate, reactivate impaired CNS
• Provide the most valid, reliable, and current
education/rehabilitation concerning
neuralplasticiy
Potential Physiological Effects/Changes
Resulting from Intensive Rehabilitation
• Increased O2 , hemoglobin, and EMG activity in the paralyzed
limb (Kaashima etal 2005)
• Possible gene expression and synaptic re-organization
following FES (Donaldson etal 2000, Dobkins 2003, Keyvani etal
2004)
• Improved leg function and over ground ambulation with FES,
and BWSTT combined with FES (Donaldson etal 2000,
Mirbagheri etal 2002, Postans etal 2004)
• Increased production/secretion of brain derived neurotrophic
growth factor (BDNF) (Gomez-Pinilla etal 2002, Kleim etal 2003)
• Rehabilitation may need to first focus on influencing the older
motor systems of the CNS (Wakabayashi et al 2001, Kakebeeke
etal 2005)
Proposed
Intensive Rehabilitation Parameters
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1-3 hours of therapy 3 to 5 days per week
Couple the entire body when ever possible
Implement closed chain exercise whenever possible
Implement exercises that take clients through
numerous levels of developmental sequences in
addition to pre-gait/gait training
• Provide an enriched environment for all therapy
procedures
• The activity should be novel, complex, and involve indepth cognitive processing
Relevance to Rehabilitation
• In order to develop appropriate and efficient
therapy programs for clients with TBI, several
rehabilitative neuro-plastic paradigms must be
considered.
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The appropriate timing of physical rehabilitation
The appropriate type of physical rehabilitation
The appropriate intensity of physical rehabilitation
The appropriate environment for physical
rehabilitation.
When should rehabilitation begin?
• Education should begin from day one
• Initiation of Intensive Physical Rehabilitation is
dependent on:
– Date of Injury
– Nature/Type/Location of Injury
– Comorbidities
• There maybe an initial period in which rest is the
most beneficial treatment for optimal recovery
What is Intensive Rehabilitation ?
• There is currently no literature that accurately defines
intensive rehabilitation
• There is limited literature investigating the most efficient
therapeutic exercise, treatment duration, and treatment
intensity (Harkema, Field-Foote)
• Outcome measures are currently being designed and
investigated for accuracy (validity & reliability)
• There maybe benefit to focus physical rehabilitation on
coordination/activation of older motor systems
(Kakebeeke etal 2005)
Neuralplasticity Defined
• Neuralplasticity is the ability of neurons to alter their
structure or function in the presence of an adequate
stimulus or following perturbation.
Examples include:
• Axonal Regeneration
• Long-Term Potentiation
• Denervation Supersensitivity
• Collateral Sprouting
• Dendritic Pruning
• Cortical Reorganization
Learned Non Use Model
Injury
Unsuccessful
Motor
Attempts
Failure
Behavior
Suppression
Masked
Ability
Learned
Nonuse
Compensatory
Behavior
+ Reinforcement
Reinforcement of
less effective behavior
Figure recreated from Taub et al. 1997
Long-Term Potentiation (LTP)
• Long-Term Potentiation is a long-lasting increase
in effectiveness of nerve conduction following
high frequency stimulation of sensory (afferent)
fibers
• Simply put, when a nerve pathway is adequately
stimulated, it becomes more responsive to
subsequent stimulation
Denervation Supersensitivity
 Neurons that lose a synaptic input
become more sensitive to the application
of the involved neurotransmitter.
 One example is Parkinson's disease
Collateral Sprouting
• When a nerve undergoes injury, sprouting of
neurites from neighboring spared axons occurs.
• When injury occurs in the CNS, the distance of
growth is generally restricted to 250  m.
• The functional significance of collateral sprouting
is not known.
• Collateral sprouting may be of benefit to subjects
with spinal cord injuries due to the correlation
between sprouting and hyperreflexia.
Example of Collateral Sprouting
http://www.jccc.net/~aalarabi/axonreg.html
Dendritic Pruning
• Loss or altered innervation may result in modified
post-synaptic neuronal structure/morphology
• Segregation of the altered inputs occurs in different
regions of the dendritic tree
• If this results in a reduction or loss of sensory
pathways, there is a selective reduction in the size of
the affected dendritic arbor
Example of Pruning
http://www.jccc.net/~aalarabi/axonreg.html
What are Central Pattern Generators (CPG)?
• “CPGs refer to functional networks that
generate rhythm and shape the pattern of
motorneurons” Zher etal 2004
• Examples are the rhythmic movements
seen in crawling, walking, running,
swimming…
What is the difference between
volitional and autonomic movement?
• “What is volitional in voluntary movement is
its purpose” MacKay-Lyons 2002
• The same motor programs are involved for
both volitional and autonomic movements
• The environment or situation greatly influence
the coordination between the cortex (your
mind) and spinal cord (CPG)
Dendrites with
loss of
connections
Numerous connections between uninjured
neurons still exist, collateral sprouting or
pruning may occur
Cortical Reorganization
• Neuronal connections and cortical maps are
continuously remodeled by our experiences or in
response to CNS injury
• This may be the result of neurogenesis, LTP,
unmasking of preexisting connections or increased
synthesis of neurotrophic factors
• We must make sure that the reorganization and/or
neuroplastic changes are positive/wanted
Cortical Reorganization
Field-Fote 2004
• Artificial stimulation (electrical, vibrational) applied to sensory fibers
can modify CNS circuitry
• Electrical stimulation (ES) may be more effective with upper motor
neuron injuries in reducing the stretch reflex along with other forms
of inhibition
• Effective prolonged stimulation of peripheral nerves has the potential
to increase the excitability of the motor cortex
• Additionally, sensory level ES combined with training may help
prevent/reverse the maladaptive reorganization of the cortex and
spinal cord
Summary: Multiple studies have shown that sensory stimulation of an
impaired limb (TBI, CVA,SCI) results in improved function of the
limb. This indicates reorganization of the brain
Cortical Reorganization
Kleim et al 2003
• This article reviewed current research looking at motor enrichment
associated with exercise and the induction of plasticity before or
after brain injury
• Functional activity, treadmill training, and forced use have all
demonstrated some form of improved “brain health”
• This may be in the form of neurotrophic factors, neurogenisis,
synaptogenesis, pre/post synaptic modulation
• Exercise has shown a “prophylactic effects with TBI and CVA”
In other words to help prevent more severe damage
• It is possible that exercise has the potential to reactivate plastic
mechanisms in chronic brain injury
Summary: Combined use of multiple muscles during exercise/activities
seems to have a beneficial effect on the CNS
Cortical Reorganization
Thomas et al 2005
• Ten individuals (ASIA C & D, age 29-78) with Incomplete SCI under
went body weight support treadmill training (BWSTT) for one hour 35 days/wk for 3-5 months
• Subjects performed BWSTT on a motorized treadmill with manual
assistance for leg movement
• Cortical (Brain) Stimulation to certain muscles was provided via
transcranial magnetic stimulation (TMS)
• Intense BWSTT combined with TMS increased the connectivity of
spared corticospinal pathways (Central Effect)
• Further research is needed to clarify the correlation between motor
improvement and locomotor function
Summary: Stimulation of specific areas of the brain lead to strong
contractions of leg muscles indicating that the change occurred in
the spinal cord and not the muscle
Cortical Reorganization
Field-Fote 2004
• Review article exploring how electrical stimulation (ES)
modifies spinal and cortical neural circuitry
• Sensory information is essential for refined coordinated
motor tasks
• This information regulates spinal reflexes
• This sensory information becomes disorganized or non
existent with neurological injuries (TBI, CVA, SCI)
• Long-term reflex plasticity can be operantly conditioned
(simple stated, a given stimulus can help relearn a
movement when the movement is properly reinforced in
the correct environment)
Cortical Reorganization
Field-Fote 2004
• Artificial stimulation (electrical, vibrational) applied to sensory fibers
can modify CNS circuitry
• Electrical stimulation (ES) may be more effective with upper motor
neuron injuries in reducing the stretch reflex along with other forms
of inhibition
• Effective prolonged stimulation of peripheral nerves has the potential
to increase the excitability of the motor cortex
• Additionally, sensory level ES combined with training may help
prevent/reverse the maladaptive reorganization of the cortex and
spinal cord
Summary: Multiple studies have shown that sensory stimulation of an
impaired limb (TBI, CVA,SCI) results in improved function of the
limb. This indicates reorganization of the brain
Cortical Reorganization
Taub et al 2003
• Review article exploring constraint induced movement therapy and the
need to bridge the gap from primate laboratory to human CVA
rehabilitation
• Constraint induced movement therapy has the potential to significantly
reduce motor deficient with individuals suffering form chronic CVA’s
• The cortical re-organization is use dependent
• Two modifications have been made to existing constraint induced
theory
– More intense use of the affected arm
– Less restraint of the less-affected arm
• “It is not the constraint in CI therapy that is important, it is the intensive
practice of correct use with the affected limb”
Summary: Research indicates that more intense use of the impaired limb
results in improved function indicating reorganization of the brain
Potential Physiological Effects/Changes
Resulting from Intensive Rehabilitation
• Increased O2 , hemoglobin, and EMG activity in the paralyzed
limb (Kaashima etal 2005)
• Possible gene expression and synaptic re-organization
following FES (Donaldson etal 2000, Dobkins 2003, Keyvani etal
2004)
• Improved leg function and over ground ambulation with FES,
and BWSTT combined with FES (Donaldson etal 2000,
Mirbagheri etal 2002, Postans etal 2004)
• Increased production/secretion of brain derived neurotrophic
growth factor (BDNF) (Gomez-Pinilla etal 2002, Kleim etal 2003)
• Rehabilitation may need to first focus on influencing the older
motor systems of the CNS (Wakabayashi et al 2001, Kakebeeke
etal 2005)
Neuralplastic Rehabilitation Paradigms
• Forced-Use or Constraint-Induced Model
• Traditional Model
• PNF
• NDT
•
Intensive Coordinated Rehabilitation
• Environmental Enrichment Model
Forced-Use/Constraint-Induced Model
• Constraint-Induced (CI) movement therapies evolved
from animal deafferentation research that strongly
suggested the lack of involved extremity use may be
result of learned non-use (Taub,1997, 2003).
• CI therapies focus on restricting the use of the
unaffected extremity by different means (casting,
sling, padded mitten) thereby forcing the use of the
affected limb.
• Research, involving CI therapies on both animal and
human models, has demonstrated significant
improvements of motor function in the involved
extremity (Dromeric, 2000; Liepert, 2000; Schallert,
2000; Taub, 1997, 2003; Whitall, 2000)
Forced-Use or Constraint-Induced Model
Large and Small Well experimental setup (Nudo et al, 1997)
Small Well
Large Well
Forced-Use or Constraint-Induced Model
These results indicate that cortical reorganization is
effected by learning new motor skills, not repetitive
motor use (Nudo et al, 1997).
Nudo etal (1997)
Traditional Models
• Proprioceptive Neuromuscular Facilitation (PNF)
• Neurodevelopmental Treatment (NDT)
Proprioceptive Neuromuscular Facilitation (PNF)
• Proprioceptive neuromuscular facilitation is a philosophy and
treatment method developed by Dr. Herman Kabat with later
help from Margaret Knott and Dorothy Voss (Adler, 2000).
• PNF is a common physical therapy treatment employed to help
restore motor function in patients who have sustained various
CNS insults (Adler, 2000).
• Basic procedures of PNF include the combination of manual
contact, resistance, stretch, timing, traction/approximation,
stimulus irradiation and verbal guidance to produce synergistic
mass movements or movement components necessary for
normal motion (Adler, 2000).
Neurodevelopmental Treatment (NDT)
• The NDT concept was developed by Karel and Berta Bobath in
1943 with the intention of this treatment to be delivered by
three disciplines, physical therapy, occupational therapy, and
speech-language therapy (DeGangi, 1994).
• Their treatment concept was originally designed in an effort to
improve the function of individuals who had experienced a CVA
and was later applied to individuals with cerebral palsy
(DeGangi, 1994).
Neurodevelopmental Treatment (NDT)
• NDT approach addresses three main areas of function, postural
control, transitional movement, and functional activities within
a given posture.
• There is little scientific evidence concerning assumptions on
the neurophysiology, and efficacy of the NDT approach
(Fetters, 1996; Lennon, 2000).
• Even though the NDT approach is widely applied in various
clinical practices, controversy still exists as to what exactly
constitutes: NDT, the appropriate environment for the delivery,
and the appropriate treatment duration.
Neurodevelopmental Treatment (NDT)
Lennon (2000) suggested that future researching
concerning the efficacy of NDT should consider
defining the following:
• A theoretical rationale for the delivery of treatment
• Parameters of approach
• Validity and reliability of neuroplastic changes associated with
the manipulation of sensory inputs through specific handling
techniques
Environmental Enrichment Model (EE)
• The first reports of environmental influence on problem solving
skills was reported in 1949 (Schallert, 2000).
• In this study, pet rats demonstrated improved problem- solving
skills when compared to experimental rats caged in standard
housing (Schallert, 2000).
• This discovery led to the hypothesis that an enriched
environment allowed for the use of new experiences(Schallert,
2000, Biernaskie et al 2001)
• EE rehabilitation may act to modify and strengthen connections
that are inherently formed after brain injury resulting in
improved functional outcomes (Biernaskie et al 2001)
Recovery vs Adaptation
• What is the difference?
• Does it really matter or is it semantics?
• Do certain therapeutic exercises or pieces
of therapeutic equipment promote
recovery?
Therapeutic Exercise
and Equipment
What is the most beneficial?
• Full body ergometer
• Total Gym (couple the entire body)
• PNF, NDT, manual therapy
• Dynamic standing frame (or dynamic upper extremity activity
in static frame)
• FES bike
• Whole Body Vibration (WBV)
• Body weight support treadmill training (BWSTT)
• Second Step Gait System and over-ground training
Body Wgt Support Treadmill or Overground Training?
• Conventional over-ground gait training is more
effective in improving gait symmetry n individuals with
chronic TBI (Brown et al 2005)
• The physical therapy strategies of body weight
support on a treadmill and defined overground
mobility therapy did not produce different outcomes
(Dobkins etal 2006).
• BWSTT is being used throughout the world…after
SCI. This therapy, however, is very labor-intensive,
and recent evidence suggests that it may not be
superior to other more conventional forms of
rehabilitation ( Hicks etal 2008).
Lower Extremity Bracing
• Why brace?
– Safety
– Independence
• What are the choices or alternatives
– Adjustability
– Electrical bracing
• Common mistakes
– Learned non-use
– No follow up for progression or modification
Potential Health Benefits
• Cardiovascular
• Immunological
• Musculoskeletal
Cardiorespiratory Conditioning After TBI
Hassett et al 2008
• Primary objective was to evaluate whether fitness
training improves cardiorespiratory fitness in people with
TBI
• 10 electronic data bases were searched
• Results demonstrated clinical diversity with regard to the
interventions, time post-injury and the outcome
measures used (could not pool data)
• Cardiorespiratory conditioning was improved in one
study (6 studies, 300 total subjects)
• Insufficient evidence to draw conclusion about fitness
training and cardiorespiratory benefits
Serum-mediated osteogenic effect
in traumatic brain-injured patients
• Gautschi et al 20009
• Aim of this study was to investigate whether
serum from TBI patients is osteoinductive
• Results demonstrated a higher mean
proliferation rate of primary human osteoblasts
at all time points of sampling
• Conclusion, there is humoral mechanism
• Question: How do we maximize humoral
mechanisms after TBI’s?
Exercise normalizes levels of growth inhibitors
after brain trauma.
• Animal study by Chytrova et al 2009 that looked at the effect the
effects of the on protein levels of two myelin-associated molecules
(MAG and Nogo)
• One week of voluntary running wheel exercise overcame the injuryrelated increase in MAG and Nogo-A
• This was apparently the result of increased activation of BDNF
(brain derived neurotrophic factor)
• These results indicate that exercise promotes a permissive cellular
environment for repair after TBI, in a process in which BDNF plays a
central role.
Exercise Induced BDNF Production
• Griesbach et al 2009 looked at exercise and BDNF production
in animals that sustain a fluid percussion TBI
• Animals received either a placebo, BDNF inhibitor, no
accesses to exercise or exercise
• The study did provide evidence that BDNF has a major role in
exercise's cognitive effects in traumatically injured brain
• Questions
– Model of injury
– Exercise intensity, type and duration
– Environment
Recommended Articles
• Revenge of the “Sit”
– (Vaynman et al, J Neurosci Res. 2006 Sep;84(4):699-715.
• Moving the Arms to Activate the Legs
– (Ferris et al 2006, Exerc Sport Sci Rev. 2006 Jul;34(3):113-20.
• Neuroplasticity after SCI: An Emerging
Paradigm Shift in Rehabilitation
– Berhman et al 2006, Phys Ther. 2006 Oct;86(10):1406-25.
Summary
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The ability of the human nervous system to retain differing degrees of
neural plasticity throughout development cannot be overlooked by the
various disciplines of physical rehabilitation.
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Physical rehabilitation education must be modified to take into
account recent research concerning the cellular mechanism and
experimental rehabilitation techniques.
•
Current traditional models of physical therapy must begin to build a
scientific database to establish the validity and reliability of treatments
believed to enhance neuroplastic changes.
Special Thanks
Second Step
Irvine Head Injury
Level Eleven Physical Therapy
Summary
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There are numerous similarities between traditional methods of
treatment and experimental models reporting neuroplastic effects to
warrant this exploration.
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Evidence of neuroplastic changes resulting from experimental
rehabilitation support expansion and divergence from traditional
compensatory strategies following insults to the CNS.
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We must continue to perform research that will allow us to make sure
that these neuroplastic changes are of benefit to the patient.
Summary
As therapists, we must realize that our treatment
technique, treatment intensity, treatment duration and
environment in which it is provided has the potential to
evoke neuroplastic changes in every patient, not just
those who have a disturbance of the CNS.