il training del cammino nel malato di Parkinson. PELOSIN

Apprendere osservando,
apprendere imitando in
età adulta:
il training del cammino
nel malato di Parkinson
Elisa Pelosin
Centre for Parkinson’s Disease
and Movement Disorders
University of Genoa
Il training del cammino nel paziente affetto da malattia di Parkinson
1
4
Ancona,
28-29 Novembre 2013
Motor Learning and PD Rehabilitation
2
Evidences of effective rehab. strategies for gait in PD
3
Action Observation Therapy in improving walking in PD
New perspectives…..
Il training del cammino nel paziente affetto da malattia di Parkinson
MOTOR LEARNING
PROCESS
PHYSICAL THERAPY
Ancona,
28-29 Novembre 2013
Rehabilitation may be seen
as a learning process
where old skills
have to be re-acquired
and new ones
have to be learned
on the basis of practice
Il training del cammino nel paziente affetto da malattia di Parkinson
Motor learning is still preserved in
patients with Parkinson’s disease???
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Doyon & Benali, 2005
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
MOTOR LEARNING PROCESS
PHASE
INITIAL
LATE
STRUCTURES
Associative regions
Sensorimotor regions
BG/ prefrontal cortex BG/ sensorimotor
cortex
LEARNING
Reward based/goal
directed learning
Habitual
learning/automatic
motor control
Il training del cammino nel paziente affetto da malattia di Parkinson
In PD, differential loss of DA
innervation from sensorimotor
regions in the basal ganglia
causes dysfunctional output
signals from these territories
and their associated network.
This loss of function causes an
increased reliance on goal
directed control.
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
MOTOR LEARNING PROCESS
PHASE
INITIAL
LATE
STRUCTURES
Associative regions
Sensorimotor regions
BG/ prefrontal cortex BG/ sensorimotor
cortex
LEARNING
Reward based/goal
directed learning
Habitual
learning/automatic
motor control
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Which type of rehabilitation strategies can be
useful in improving gait and motor learning?
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Motor/cognitive combined approach
1. CUED FUNCTIONAL
TRAINING
2. ACTION
OBSERVATION
Motor/cognitive
combined approach
4. AUGMENTED
FEEDBACK / VIRTUAL
REALITY
3. MOTOR IMAGERY
Il training del cammino nel paziente affetto da malattia di Parkinson
When ??
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
It has been suggested to use motor/cognitive strategies
in 2≤H&Y≥3.5 (ref. 2013 EU Guidline for Physioterapy)
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Motor/cognitive combined approach
1. CUED FUNCTIONAL
TRAINING
2. ACTION
OBSERVATION
Motor/cognitive
combined approach
4. AUGMENTED
FEEDBACK / VIRTUAL
REALITY
3. MOTOR IMAGERY
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Cueing is defined as the use of external temporal or spatial stimuli to
facilitate movement or motor activities (gait) initiation and continuation.
Nieuwboer A. – Rescue Trial - 2007
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
which kind of cues in PD?
Acustic
Rytmic,
metronome
Music
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
which kind of cues in PD?
Acustic
Rytmic,
metronome
Visual
Real (lines
Music
on the floor)
Virtual (glasses)
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
which kind of cues in PD?
Visual
Real (lines
on the floor)
Virtual (glasses)
Somatosensory
Proprioceptive
Electircal stimuli
Il training del cammino nel paziente affetto da malattia di Parkinson
Using “cueing” to improve mobility in Parkinson’s Disease
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
What we know on cueing therapy ?
• Cueing therapy is particularly effective for gait in PD (FOG)
• Spatial (visual) cues may correct and regulate step length
Morris et al. - Brain 1996
• Temporal (auditory) cues are the most likely to stabilize gait timing
McIntosh et al. - JNNP 1997
• Recently, freezing-like episodes occuring during finger movements has
been studied in PD-FOG+. Patients with FOG also benefit from
auditory cueing during upper-limb movements, but these are highly
cue dependent.
Vercruysse et al. – NRNR 2012
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
What we know on cueing therapy ?
• Cueing therapy is particularly effective for gait in PD (FOG)
• Spatial (visual) cues may correct and regulate step length
Morris et al. - Brain 1996
• Temporal (auditory) cues are the most likely to stabilize gait timing
McIntosh et al. - JNNP 1997
• Recently, freezing-like episodes occuring during finger movements has
been studied in PD-FOG+. Patients with FOG also benefit from
auditory cueing during upper-limb movements, but these are highly
cue dependent.
Vercruysse et al. – NRNR 2012
LIMITATIONS:
• Cueing teraphy points to trigger submovements in a movement sequence and
does not help in the acquisition of the entire movement
• Cues-dependance: cueing teraphy is not the best instrument to facilitate
consolidation of motor learning
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
There are some evidences in favor of specific strategies in
improving motor learning in PD?
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Motor/cognitive combined approach
1. CUED FUNCTIONAL
TRAINING
2. ACTION
OBSERVATION
Motor/cognitive
combined approach
4. AUGMENTED
FEEDBACK / VIRTUAL
REALITY
3. MOTOR IMAGERY
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Motor/cognitive combined approach
1. CUED FUNCTIONAL
TRAINING
2. ACTION
OBSERVATION
Motor/cognitive
combined approach
4. AUGMENTED
FEEDBACK / VIRTUAL
REALITY
3. MOTOR IMAGERY
Il training del cammino nel paziente affetto da malattia di Parkinson
why
Ancona,
28-29 Novembre 2013
… observing motor
performance….
what
how
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Why it could be useful to observe motor performance?
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Why it could be useful to observe motor performance?
IS PART OF HUMAN BEHAVIOR
MIRROR NEURONS SYSTEM IS INVOLVED
MOTOR IMITATION
CAN EFFECT NEURAL CIRCUITS REORGANIZATION
SCIENTIFIC EVIDENCE ARE GROWING…
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Mirror Neurons System is preserved in PD?
Il training del cammino nel paziente affetto da malattia di Parkinson
31
Ancona,
28-29 Novembre 2013
FREEZING of GAIT: Definition
“a brief, episodic absence
or marked reduction of forward progression of the feet
despite the intention to walk’’
(Giladi and Nieuwboer 2008 ; Nutt et al. 2011 )
FREEZING of GAIT: Definition
“a brief, episodic absence
or marked reduction of forward progression of the feet
despite the intention to walk’’
(Giladi and Nieuwboer 2008 ; Nutt et al. 2011 )
FREEZING of GAIT: Definition
“a brief, episodic absence
or marked reduction of forward progression of the feet
despite the intention to walk’’
(Giladi and Nieuwboer 2008 ; Nutt et al. 2011 )
FREEZING of GAIT: Clinical aspects
1) Is a common problem in PD: affecting about 50% of patients, and up to 80 % in the
advanced stages (Morris et al. 2008 ; Tan et al. 2011 ).
2) It is a highly debilitating symptom, as it may lead to falls, decrease QoL and induce loss of
independence (Bloem et al. 2004 ; Moore et al. 2007 )
3) It occurs both during OFF and ON
4) It is increased by “stressful or anxious” situations
5) The risk of FOG increase when patients are asked to perform a secondary task (Giladi and
Hausdorff 2006 ; Rahman et al. 2008 )
CUEING THERAPY & FOG
35
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
• MEASURE:
• FOG Questionnaire (6-item
questionnaire that has been shown to be a valid and
reliable outcome measure in patients with PD) and FOG diary (monthly calendar, in
which all participants were instructed to record, for every single day, the number of freezing
episodes in different circumstances)
• Motor performance (Timed Up and Go Test, the 10-meter walking test, and the
Tinetti Scale, Berg Balance Scale) and quality of life (The 39-item PD
questionnaire was used to assess QoL)
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Both groups performed 4 weeks of treatment; 3 x weeks = 12 sessions
Control Group
AOT Group
(cases)
• 6 video clips showing strategies useful in circumventing FOG
episodes.
• Actions were presented in a fixed order according to their
complexity
• After observation of each video PD patients were asked to
practice the observed actions repetitively and accurately
according to the instructions of the physical therapist.
• video clips containing sequences of static pictures of mountains
and seaside, countryside, and desert scenes without any living
(human or animal) representations.
• After observation of each video PD patients were asked to
perform the same movements/actions used for the Action group
following the physical therapist’s instructions, in the exact order
and for the same amount of time.
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Both groups performed 4 weeks of treatment; 3 x weeks = 12 sessions
Control Group
AOT Group
(cases)
• 6 video clips showing strategies useful in circumventing FOG
episodes.
• Actions were presented in a fixed order according to their
complexity
• After observation of each video PD patients were asked to
practice the observed actions repetitively and accurately
according to the instructions of the physical therapist.
• video clips containing sequences of static pictures of mountains
and seaside, countryside, and desert scenes without any living
(human or animal) representations.
• After observation of each video PD patients were asked to
perform the same movements/actions used for the Action group
following the physical therapist’s instructions, in the exact order
and for the same amount of time.
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Although the efficacy of cues to
improve management of FOG is
well known, combining action
observation with acoustic cue
seemed not to be effective,
probably because the cue
constituted a distracting factor.
Il training del cammino nel paziente affetto da malattia di Parkinson
What observed in a rehabilitative setting?
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
What observed in a rehabilitative setting?
“DIFFERENTS ACTIONS (ECOLOGICAL – GOAL DIRECTED – SPECIFIC)
ALL THE ACTIONS SHOULD SELECTED FROM ITHE OBSERVER’S REPERTOIRE
ACTIONS RELATED TO THE IMPAIRED FUNCTION
ACTIONS WITH INCREASING DIFFICULTIES
STIMULI LEADING TO SIMILAR BODY MOVEMENTS
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
How AOT should be used in a rehabilitative setting?
“ACTIVE PARTECIPATION AND ATTENTION FROM THE OBSERVER”
FKT SHOULD DECIDE IF USE ISTRUCTIONS
FOCUS ATTENTION OF DIFFERENT PROPERTIES OF MVNTs
AO + REPETIONS OF WHAT HAS BEEN OBSERVED
AOT NEEDS TO BE INSERTED IN TO A REHAB PLAN
Take home messages
• AOT is not “a simple watching”. It’s an “active process IMITATION
• The video-clips should be accurately selected by the PTs (actions,
perspective, kinematic aspects….) respect to the impaired motor function
• Is possible use AOT to improve specific movement aspects (velocity,
amplitude….)
• PTs should decide which type of instructions are useful for patients
• AOT can be used by patients as home-training (an initial training to the
patients is needed)
• Future research need to be done in order to verify the efficacy of AOT in
motor learning and motor performance processes
• AOT is a new tools for rehabilitation and it can be inserted as a part of
rehabilitation program
Take home messages
• AOT is not “a simple watching”. It’s an “active process IMITATION
• The video-clips should be accurately selected by the PTs (actions,
perspective, kinematic aspects….) respect to the impaired motor function
• Is possible use AOT to improve specific movement aspects (velocity,
amplitude….)
• PTs should decide which type of instructions are useful for patients
• AOT can be used by patients as home-training (an initial training to the
patients is needed)
• Future research need to be done in order to verify the efficacy of AOT in
motor learning and motor performance processes
• AOT is a new tools for rehabilitation and it can be inserted as a part of
rehabilitation program
Take home messages
• AOT is not “a simple watching”. It’s an “active process IMITATION
• The video-clips should be accurately selected by the PTs (actions,
perspective, kinematic aspects….) respect to the impaired motor function
• Is possible use AOT to improve specific movement aspects (velocity,
amplitude….)
• PTs should decide which type of instructions are useful for patients
• AOT can be used by patients as home-training (an initial training to the
patients is needed)
• Future research need to be done in order to verify the efficacy of AOT in
motor learning and motor performance processes
• AOT is a new tools for rehabilitation and it can be inserted as a part of
rehabilitation program
Take home messages
• AOT is not “a simple watching”. It’s an “active process IMITATION
• The video-clips should be accurately selected by the PTs (actions,
perspective, kinematic aspects….) respect to the impaired motor function
• Is possible use AOT to improve specific movement aspects (velocity,
amplitude….)
• PTs should decide which type of instructions are useful for patients
• AOT can be used by patients as home-training (an initial training to the
patients is needed)
• Future research need to be done in order to verify the efficacy of AOT in
motor learning and motor performance processes
• AOT is a new tools for rehabilitation and it can be inserted as a part of
rehabilitation program
Take home messages
• AOT is not “a simple watching”. It’s an “active process IMITATION
• The video-clips should be accurately selected by the PTs (actions,
perspective, kinematic aspects….) respect to the impaired motor function
• Is possible use AOT to improve specific movement aspects (velocity,
amplitude….)
• PTs should decide which type of instructions are useful for patients
• AOT can be used by patients as home-training (an initial training to the
patients is needed)
• Future research need to be done in order to verify the efficacy of AOT in
motor learning and motor performance processes
• AOT is a new tools for rehabilitation and it can be inserted as a part of
rehabilitation program
Take home messages
• AOT is not “a simple watching”. It’s an “active process IMITATION
• The video-clips should be accurately selected by the PTs (actions,
perspective, kinematic aspects….) respect to the impaired motor function
• Is possible use AOT to improve specific movement aspects (velocity,
amplitude….)
• PTs should decide which type of instructions are useful for patients
• AOT can be used by patients as home-training (an initial training to the
patients is needed)
• Future research need to be done in order to verify the efficacy of AOT in
motor learning and motor performance processes
• AOT is a new tools for rehabilitation and it can be inserted as a part of
rehabilitation program
Take home messages
• AOT is not “a simple watching”. It’s an “active process IMITATION
• The video-clips should be accurately selected by the PTs (actions,
perspective, kinematic aspects….) respect to the impaired motor function
• Is possible use AOT to improve specific movement aspects (velocity,
amplitude….)
• PTs should decide which type of instructions are useful for patients
• AOT can be used by patients as home-training (an initial training to the
patients is needed)
• Future research need to be done in order to verify the efficacy of AOT in
motor learning and motor performance processes
• AOT is a new tools for rehabilitation and it can be inserted as a part of
rehabilitation program
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Future perspectives
1. CUED FUNCTIONAL
TRAINING
2. ACTION
OBSERVATION
Motor/cognitive
combined approach
4. AUGMENTED
FEEDBACK / VIRTUAL
REALITY
3. MOTOR IMAGERY
Il training del cammino nel paziente affetto da malattia di Parkinson
Virtual Reality
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Rehabilitative setting
Ancona,
28-29 Novembre 2013
2 different environments
Il training del cammino nel paziente affetto da malattia di Parkinson
Virtual Obstacles
Puddle: modulation in step
lenght
Hurdle: modulation in step
height
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Virtual Obstacles
Feedback
Puddle: modulation in step
lenght
Hurdle: modulation in step
height
Positive Feedback
Upon a successful attempt, a visual
positive feedback will be portrayed as
two green bars appearing on the top
and bottom parts of the screen
Negative Feedback
When the patient is unsuccessful, a
negative visual feedback will appear in
the form of a flash of red light.
Il training del cammino nel paziente affetto da malattia di Parkinson
Cognitive Features
Cognitive features in the system include
1. deciding on the level of distracters,
2. environmental features relating to visibility
3. the level of signposts provided to the patient during the walk
1. DISTRACTERS
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Cognitive Features
Cognitive features in the system include
1. deciding on the level of distracters,
2. environmental features relating to visibility
3. the level of signposts provided to the patient during the walk
2. ENVIRONMENT
Potential Questions for park
environment:
1. What color was the book
the woman sitting on the
bench was reading? (Blue)
Il training del cammino nel paziente affetto da malattia di Parkinson
Cognitive Features
Cognitive features in the system include
1. deciding on the level of distracters,
2. environmental features relating to visibility
3. the level of signposts provided to the patient during the walk
3. SIGNPOSTS
3 levels: easy /medium / hard
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
During the training, motor and cognitive load should be
implemented gradually
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
Is it possible to evoke plasticity in the cholinergic circuits
with physical therapy?
Il training del cammino nel paziente affetto da malattia di Parkinson
TMS Protocol
SAI
(short latency afferent inhibition)
Protocol
(short latency afferent inhibition)
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
SAI
(mean +/-SD)
1
0.8
0.6
0.4
PD
MCI
ELD
Ancona,
28-29 Novembre 2013
Il training del cammino nel paziente affetto da malattia di Parkinson
Ancona,
28-29 Novembre 2013
More inhibition
Is it possible to evoke plasticity in the cholinergic circuits
with physical therapy?
Thanks for the attention!
Desidero Ringraziare
Laura Avanzino, Roberta Marchese, Carla Ogliastro, Carlo Trompetto, Alessia
De Ferrari, Davide Massucco, Tiziano Tamburini, Lucio Marinelli, Giovanna
Lagravinese, Ambra Bisio e Marco Bove, V-TIME consortium (Jeff Hausdorff,
Anat Mirelman, Lynn Rochester,Alice Nieuwboer, Bastian Bloem etc…..)
“ The Abbruzzese’s Team ” & some friends
Does the action needs to be identical to the reality?
Some ideas…..
Some ideas…..
Force platform
Results
“biological” - Upright
“not biological” - Inverted
Some ideas…..
Action
Observation
Protocol
Force platform
Force platform
Force platform
Results
Results
Motion recognition evokes motor resonance