This counterintuitive yet useful technique can be taught to families and caregivers to facilitate mobility in individuals with AD. Strategic use of hand placement with directional force can be equally effective to assist supine-to-sit or sit-to-stand transitions—hands should be placed giving pressure into the patient such that if the individual responds by pushing/moving his body into the pressure, the resultant movement will be in the desired direction (i.e., pushing down into the patient when you want the patient to move their body up). This strategy is not universally effective, but when it does work, it can significantly lessen caregiver burden.
Figure 4: Clinical Impact of Paratonia: Hand Placement to Facilitate Mobility
The stimulus of hands on the posterior shoulders (left) causes the client to push backwards into the stimuli; hands on the anterior shoulders (right) will facilitate the client’s anterior weight shift. Note . Illustrations copyright 2014 by Scout Ries. Used with permission.
MOTOR LEARNING PRINCIPLES AND ALZHEIMER’S DISEASE
Typical motor learning There are two major memory and learning systems that function in the context of motor learning: declarative/explicit and procedural/implicit (Shumway-Cook & Woollacott, 2017; Vidoni & Boyd, 2007). Declarative/explicit learning requires awareness and attention, is reliant on recall, and is enhanced by the ability to reflect upon and articulate the process being learned. Procedural/implicit learning comes in various forms: (a) nonassociative learning, such as habituation and sensitization; (b) associative learning, such as operant and classical conditioning; and (c) skill (and habit) learning. Figure 5 depicts these mechanisms of motor learning. The neuroanatomical home for each of the memory and learning processes is distinct. When the nervous system is functioning normally, different strategies of motor learning occur both in tandem and independently, depending on the situation and goals. Declarative/explicit learning requires functioning of the hippocampus and surrounding medial temporal lobe structures, whereas procedural/implicit learning requires functioning of the basal ganglia and cerebellum (Harrison, Son, Kim, & Whall, 2007; Shumway-Cook & Woollacott, 2017; Vidoni & Boyd, 2007). In rehabilitation, both types of learning are often integrated. Declarative learning is used when patients are asked to reflect on performance, sequence multiple activities within a task, remember and build on previous performance, or articulate their movement processes. Procedural learning is used when therapeutic programs are designed with repetitive practice of skills without encouraging conscious awareness or reflection on task performance. With purposeful use of therapeutic strategies, physical therapists have the ability to drive neuroplastic changes in the brain. Kleim & Jones (2008) authored a seminal article summarizing the principles of experience-dependent neural plasticity, highlighting evidence that supports the ability of rehabilitation professionals to impact central nervous system recovery with skillfully designed and implemented treatments. Specificity, repetition, intensity, and salience of training were highlighted as critical considerations in therapeutic interventions.
Figure 5: Mechanisms of Motor Learning
Note . Content adapted from Shumway-Cook A. and Woollacott M.H. Motor Control: Translating Research into Clinical Practice, 5th ed. (2017). Philadelphia PA: Wolters Kluwer. Baltimore, MD: Lippincott Williams & Wilkins; and Vidoni, E. D., & Boyd, L. A. (2007). Achieving enlightenment: What do we know about the implicit learning system and its interaction with explicit knowledge? Journal of Neurologic Physical Therapy, 31 (3), 145-154. Winstein and colleagues (Winstein & Kay, 2015; Winstein, Lewthwaite, Blanton, Wolf, & Wishart, 2014) offer support and guidelines for the Accelerated Skill Acquisition Program (ASAP) that put motor learning principles into a conceptual framework that is driven by the fundamental components of the skill of interest, the individual’s capacity to perform the skill, and the individual’s motivation. Their model is both theoretical and practical, and it integrates principles of neurorehabilitation, motor learning, neuroscience, exercise physiology, and behavioral science. Table 4 presents a summary of principles relevant to motor learning and skill acquisition that are important for therapists to consider in creating treatment programs for all clients. In planning practice sessions for optimal motor learning, consideration of the amount of practice, the practice conditions, and the use of feedback to best suit the needs of clients are all important. Regardless of the patient population, it is generally believed that more is better when it comes to practice.
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Book Code: PTNY3622B
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