Massed practice in neurological

rehabilitation
Johan Lambeck; in cooperation with
Marcel Hulselmans, Edina Szirki, Pter Pribly,
Nico van den Beukel, Joost Spelt
lambeck@freeler.nl
Programme
Introduction Johan Lambeck
Overview of treadmill research and
applications Marcel Hulselmans
Explanation of the possibilities of the
Aquawallgym Edina Szirki
A circuit in the pool with various pieces of
equipment and activities freely in the water
Johan Lambeck, Marcel Hulselmans, Edina Szirki, Pter Pribly, Nico van den
Beukel, Joost Spelt
Motor (re)learning in
neurology:
How to rewire the brain
What is motor (re)learning?
A theoretical concept
Principles
Massed practice
Enriched environment
Why water?
Motor learning =
Achieving a "relatively permanent change towards
skilled motor behavior, resulting from practice, also
capable of error-detecting and responding to the
constraints of the environment (Schmidt & Lee 1999)
An effective way of learning is by offering variability
of skill performance by changing context and
(bio)mechanical constraints (Schmidt and Lee)
Practice
Achievement depends on structure (quality and
quantity) of practice and feedback as well on
the interaction between the person, the task
and the environment
Dynamic Systems Model / DSM (Newell 1986)
DSM
Motor
control
Task
E
n
v
i
r
o
n
m
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n
t

Newell 1986:
The specific constraints of
the environment can
therapeutically influence the
patients motor behavior
The pool
To prevent or to change these:
Increase movement frequency and stress the neuromotor
system. The system gets instable and possibly adapts /trains.
Enrich the environment in order to stimulate the neuromotor
flexibility
Therapy >> distributed massed practice in an
enriched evironment
Bad habits
In neurology, specific motor behavior solutions will
appear and persist a bad habit (Beek, 2012).
Distributed massed practice
An intervention with repetitive practice as the
primary therapeutic factor, with distributed rest
periods (Taub 2001, Murray 2003)
A known example is constraint induced movement therapy
Goal: functional cortical (brain)
reorganization according to Taub & Nudo by
e.g synaptosis, dendritogenesis and
angiogenesis
Research
increased somatosensory activity in the same and
adjacent maps Beekhuizen 2005, 2008
2 h, 4 days/wk continuous repetition of tasks in 5
categories, 25 min per category (incomplete SCI
handfunction
Large (ss) improvements in various walking - and
balance tests Marklund 2006
chronic post-stroke patients 6 h, 5 days/week, 2
weeks. Random choice of cycling, pool training,
functional strength training in different start positions (sitting
down, stand up and lay down), weight-bearing in different
directions, stair training without use of banisters, indoor
walking/outdoor walking on uneven surfaces.
Research: case study
Sign. results in (anticipatory) balance with less
falls and more symmetrical weight-bearing
Vearrier & Shumway-Cook 2005: 1 patient post-stroke
6 h/day, 5 days/week, 2 weeks. Contents:
functional mobility: ambulation and upright static and dynamic balance
tasks
addressing impairments such as limitations in strength and ROM.
Subjects daily regimen consisted of 70% functional training, 20%
impairment related intervention, 5% disability level activities, and 5%
intermittent rests
Equipment that also was used: bicycle, treadmill, obstacles
Contextual interference
Contextual interference is a technique that involves
making the practice environment more difficult by
having learners practice several skills
interchangeably and randomly

Random (= unpredictable) variability in the form of
irrelevant movement components, necessary for
good performance
Always some minutes for every skill, but
sequence at random
Stochastic resonance
W. Schllhorn (2010)
There is no ideal movement and we cannot correct
toward that ideal movement
Mistakes are important: these give differences with
information about the best way to perform a task
Stochastic resonance = adding bias can show a
below-threshold signal > variations in environment
and task make the central nervous system react.
This cns response continues after the actual
training.
Environment enrichment
Refers to conditions that facilitate enhanced
sensory, cognitive, affective and motor
stimulation, Nithianantharajah & Hannan 2006
Environmental enrichment stimulates the
hippocampus to produce BDNF = brain
derived neurotrophic factor Sao 2010
BDNF production is also augmented during
bicycling in water by patients with Multiple
Sclerosis Bansi 2012
Keywords:
Somato-
sensory
stimulation
Modulation
of attention
Exploratory
movements
Practice needs to be
Challenging / demanding /motivating
Repetitive, yet variable
Attention taking
Arousal stimulating
Therapy
Distributed massed practice with contextual
interference in an enriched environment by random
application of variable, challenging, arousing,
motivational and attractive exercises.
Would a massed practice set-up in the pool also
reach the above mentioned idea?
Why water in (early)
neuro-rehab?
Slow instability
water as a perceptual reference surface
The patient has to react
Freedom of movement
High dose of information and motor output
Distributed massed practice
Patient can be dynamic, but grade intensity:
Easier to run, jump, sneak, walk and talk
important also for the cardiovascular/pulmonal
systems
The environment provides
Support
Hands-free: space between patient and therapist =
independence
Less force needed to elicit muscle activity
Safety
No risk to fall, but still a challenge to balance
Time to think and to react
Input to the CNS changes
We like it: Water = fun and motivates
The pool
A circuit in the pool with various pieces of
equipment and activities freely in the water
Pooltrack treadmill
Underwater bicycle
Obstacle course
Aquawallgym
TM
Stations with pictos about Halliwick activities
Aquatwister
Aquastrider
Aquawalker
Aquagym: aquaclimber, aquastrider, aquatwister
Free Halliwick like exercises
Thank you for your attention
and lets continue