Mechanics of Learning – lessons from neurorehabilitation

“Use it or lose it” – is a particularly apt description of brain function. Continuously (until death) new connections are formed between the 100 billion nerve cells which we have been born, and the 100 to 10 000 connections per neuron with others forming extensive networks makes the brain an enormously complex organ.

Probably some neuro-neogenesis (perhaps 6000 cells a day) occurs even in adulthood. Only those synapses, however, which are actively used, remain functional.

This is the basis of learning – the interaction and exchange between organism (us) and environment in problem solving tasks of daily living. Investigations on neuroplasticity in recent years have become a central topic in neuroscience, and have changed the attitude towards patients with lesions of the central nervous system.

They have also led to a better understanding of the adaptations of structures and functions of the brain according to requirements from the environment (environment being understood as the physical, psychological and social surroundings with their potentials and constraints).

In neurorehabilitation, such understanding of the interactions between organism and environment and that of learning is used and adapted in the treatment of patients with acute or chronic diseases or trauma. In reverse the observation of the changes attained during rehabilitation of such patients provides new insights into the mechanism of learning and of adaptations of brain structures and functions.

By Prof. Jurg Kesselring, Department of Neurology & Neurorehabilitation, Switzerland.

This article was first published in the Brain Association of Queensland Synapse magazine. www.synapse.org.au

Neuroplasticity

Researchers used to believe the brain pathways (for sending messages between the brain and the body) were fixed or unchangeable. This meant if a function was performed by a certain area of the brain, it could only be performed by that area. Therefore, after stroke they believed any damage that wasn’t repaired within a few months would be permanent.

Research now indicates the brain has the ability to change. This means brain pathways can change. This ability is called neuroplasticity. As a result, some stroke survivors may be able to retrain the brain by learning to use different parts of their brains to regain function during rehabilitation.

For a video about Neuroplasticity from Dr Norman Doige

There are a number of great puzzle games that can help you to exercise your brain IQ Puzzler are some great ones

image via health-and-hygiene.com

An injury can disrupt the complex subsystems in our brain that provide our eyesight.

A brain injury can lead to focusing problems, eye muscle coordination deficits, changes in eyeglass perception, and peripheral vision changes. The type and extent of any visual problem depends on the severity and location of the injury. Even when visual problems are diagnosed there is often little vision rehabilitation offered. This is unfortunate as treatment often provides relief from visual symptoms. Some symptoms to look for are:

Headaches from visual tasks
Blurred or double vision
Sensitivity to light
Inability to concentrate or focus
Reading or comprehension difficulties
Trouble judging distances
Sore eyes
Loss of visual field

If you find it difficult to process visual information you may be straining without realising it. A general sense of fatigue can arise from visual problems.

Common visual problems

Dry eye

This can result when nerves or muscles of the eyelids are affected. Symptoms are often relieved with the use of the correct eye drops. In bad cases plugs placed in the tear ducts can solve the problem.

Double vision

This condition may cause confusion and disorientation. People experiencing this condition are often given an eye-patch to cover one eye, although it reduces the field of vision and interferes with daily function. Double vision can often be prevented without an eye patch, through the use of prisms and vision therapy. Prisms are used to shift objects in the field of vision. They can correct problems between body image and perception of space.

Loss of visual field

This loss is a common visual effect of a brain injury. There are many kinds but the most common is loss of half the field of vision in each eye. People frequently bump into objects, and easily trip or fall over objects. They may be afraid of leaving home and have difficulty reading. Therapy can help to detect objects on their ‘blind-side’ and use constant scanning to compensate. Compensatory strategies are useful, such as always aligning oneself to objects or people so they are centred in the remaining visual field.

Prisms and mirror devices are often helpful in cases of visual field loss. Tiny mirrors attached to glasses can expend visual field awareness. If there is some remaining vision, stimulatory exercises can be used to increase light sensitivity and regain some lost function.

Reading difficulties

These may arise from blurred or double vision, jerky eye movements, or visual field loss. Treatment can involve aids such as prisms or using a typoscope to focus on individual sentences. After injury, it can be hard to focus on a page due to nerve damage that effects the eye refocussing. Bifocal glasses can compensate.

Impaired eye movements may prevent smooth reading along a page. Therapists may be able to rebuild reading skills to reduce problems such as this.

Low vision

Following a brain injury some people have normal field of view but can’t read print or watch television with conventional glasses because of low vision. Low vision aids include telescopic lenses for distance vision and other fine tasks.

Photosensitivity

Light sensitivity varies from person to person. Some have no trouble, but others find bright light painful. Solutions may include tinted eyewear or amber filters. Sometimes treatment for other problems will reduce photosensitivity.

Hallucinations

Visual hallucinations may be formed objects such as a person or figure or may be unformed such as flashes of lights, stars or flickering distortions.

Impaired visual memory

Memory is often impaired after stroke or head injury. In rare cases very specific types of memory processing are impaired. A person may no longer be able to recognise faces, objects or letters.

Vision rehabilitation

After a brain injury, some people experience a natural recovery in the following months. Recovery can be assisted with the use of any prescription lenses. Some people will not recover naturally, but may do so with vision therapy. Vision therapy hastens natural recovery as well.

A clinician skilled in both low vision and brain injury will understand the interaction of these problems, and be able to make a plan to rehabilitate the visual system. After evaluation examination and consultation, a clinician will determine how a person processes information after an injury, and where that person’s strengths and weaknesses lie. They provide treatment designed for each person, and frequently incorporate combinations of lenses, prisms, low vision aids and vision therapy activities. The road to recovery needs teamwork of many doctors and therapists with time and patience throughout the rehabilitation process.

Ring the Optometrists Association on your state for a list of optometrists and opthamologists, or visit the national website at www.optometrists.asn.au

This article was first published in the Brain Association of Queensland Synapse magazine. www.synapse.org.au

After Stephanie Ho suffered a stroke, top-notch medical care saved her life. But when it came to regaining the use of her arm, Stephanie and her family were left to work it out on their own.

NeuRA’s Dr Penelope McNulty is developing innovative training techniques to fill this gap in services.

The day of Stephanie Ho’s stroke started out like any other Saturday in the life of a typical 22 year old. Out late the night before, she’d slept-in until midday. But when she woke, her world had completely changed.

“The first thing I did was go to brush my teeth,” says Stephanie. “My mum was there and asked me how my night was. I wanted to say ‘it was really good’, but what came out was this strange sound. No proper words came out.”

In shock, Stephanie went to find her older brother, Mark. “I was trying to type on his keyboard, but I couldn’t string two words together. Shortly after, I completely toppled over on my right side. My poor brother, he didn’t know what was wrong. He knew that, at my age, people don’t have strokes.”

What no one could have known was that lying dormant in her brain since birth was an arteriovenous malformation. That morning, this abnormal cluster of blood vessels burst, leaving Stephanie completely paralysed on her right side.

Her family rushed her to the hospital, where she stayed for almost three months. “The first week was horrible, horrible. My vision was impaired. I couldn’t move. I couldn’t talk. It was scary, to say the least.”

Gradually, with the help of physiotherapists and speech pathologists, Stephanie learned how to walk and speak again. But she still couldn’t muster much more than a flicker from her fingers. “My movement was very, very limited. I just took my right arm out of the equation. I couldn’t do anything functional at all.”

Determined to find a solution, Stephanie’s brother Mark, a researcher himself, tracked down NeuRA’s Dr Penelope McNulty, who was developing rehabilitation techniques to improve arm and hand movement using virtual sports on Nintendo Wii.

“There is a real lack of services for people who’ve had a stroke,” says Dr McNulty.

“Because arm and hand movement isn’t considered critical, rehabilitation in this area has been somewhat neglected. But being able to pick up a cup or hold a pen makes a huge difference to a person’s ability to live independently.”

In a recently published study, Dr McNulty has shown that intensive, two-week training can result in significant improvements in movement in affected limbs. “Every patient noticed improvements, not just using the Wii, but in activities they do every day, such as opening a door or using a fork. This type of rehabilitation, using virtual reality, motivates participants to complete their therapy, which is essential for recovery to take place.”

Stephanie says the training at NeuRA not only improved her range of movement, encouraging her to achieve simple things like holding her toothbrush to put toothpaste on; it also helped her regain her confidence to make a full recovery and tackle larger goals like going back to work.

“Before the Wii therapy, I was too scared to test myself. But being a part of this research helped me to try, and while I didn’t do it perfectly at first, I still did it, and for me that was inspiring.”

Read more about our stroke research. www.neura.edu.au

Life after stroke - Stephanie practises her swing using the Nintendo Wii “There is a real lack of services for people who’ve had a stroke.”

Many people love to garden and it can provide gentle to strenuous exercise for all fitness levels depending on how you go about it. Returning to everyday activities and hobbies, like gardening, after a stroke can be difficult but it is possible to modify the way you go about it so you can still get some enjoyment out of your favourite pastime – whether you tend to plants indoors or if you have an outside garden that needs care.

Gardening can also support your rehabilitation after a stroke. Thirty minutes a day is excellent but remember you can break that down into three 10-minute sessions. Always stop and rest if you feel tired or breathless.

The Better Health Channel website offers some tips on how to garden when you are living with a disability - remember gardening equipment can be modified but look for lightweight tools.

Other tips:
• raise garden beds for easier access,
• use a table to pot if you are in a wheelchair,
• use containers with wheels so they can be moved around easily,
• have a supply of water close by,
• wear hats and sunscreen when working outside, and
• vertical gardens, which make use of walls, can be more accessible than plants at ground level.

www.betterhealthchannel.vic.gov.au

Some terrific ideas and fact sheets on gardening, written especially for people who have heart disease or have had a stroke, are available from a UK website called Thrive. Their resources can be downloaded for free and include step-bystep how-to guides and pictures to support the text.

The resource, called Gardening for Hearts and Minds, covers getting started in the garden; planting and pruning; weeding and maintenance and tips and tools.

www.thrive.org.uk

In 2011, the National Stroke Foundation (NSF) Stroke Services team increased its capacity to focus more on education and resource development. One of our initial activities centred on improved adherence to the best-practice recommendations for lifestyle modification contained in the Clinical Guidelines for Stroke Management.

Lifestyle modification is an essential strategy to reduce the risk of secondary stroke. We evaluated the barriers to the provision and documentation of lifestyle advice post stroke and produced resources in consultation with a range of health professionals.

We developed the workshop ‘Motivational interviewing for lifestyle change after stroke’ with Dr Stan Steindl to provide motivational interviewing (MI) training. MI can help you deliver lifestyle modification advice that recognises your patient’s values, knowledge and desire to change.

The workshop lecture and a role play demonstrating MI in practice are now available on our website. We encourage you to watch these videos to learn more about this technique that has been shown to benefit patient mood and mortality post stroke.
This workshop is supported by a range of practical resources to aid your discussions with patients:

‘Help lower stroke risk with lifestyle modification’ clinical poster

‘Lifestyle modification discussion guide’

‘Documenting lifestyle modification advice’ information sheet

‘Meaningful patient engagement’ information sheet

‘Secondary stroke prevention: Addressing lifestyle risk factors and behaviour modification’ PowerPoint presentation

All of these resources are available here.

Image Via: themagnetos.com

This article was first printed in Synapse Bridge Magazine Vol-5. Official journal of The Brain Injury Association of Queensland.

Everyone has problems from time to time. Some are minor while others are of major concern. However, for someone who has suffered a brain injury, even the otherwise minor problem magnifies to enormous proportions if compensatory strategies are not used to control the situation.

Since I have been adjusting to my life to compensate for my brain injury for many years now, I  make use of my compensatory strategies on a regular basis to deal with cognitive problems. Cognitive rehabilitation makes living with brain injury tolerable and enables a more satisfying life.

Larry and I usually ride together if we are going to grab a bite to eat. Due to my lack of peripheral vision, which makes driving a challenge. Larry usually does the driving. On this day, he had been doing some electrical work around the house and was tired, so I offered to pick up lunch at Sonic. He agreed and I was on my way with the list of what to order (another strategy).

When it was time to leave Sonic, my car wouldn’t start. Anyone who is familiar with brain injury is not surprised that my first reaction was panic. “oh no- Why is this happening to me? What do I do now?”

Then I took a deep breath and asked myself to pull a strategy out of the tool chest. After determining which strategies fit the situation and which to use first, I reached for my phone to call Larry to let him know what happened. He was soon on the way to the rescue with jumper cables. In the meantime, I retrieved my owner’s manual from the glove box just in case it was not just the battery (planning ahead). Rather that becoming emotional, I was trying to figure out how to best solve the problem. That’s a big change from when I had no strategy to remain calm and develop a plan.

The car did not start with a jump so we had to leave it there overnight while we figured out what needed to be done. I informed the manager of the plan to temporarily leave my car there. He was very understanding and told me he would make sure it was not towed away before we returned.

The next morning, after reading the manual and doing some research on the internet, we replace a fuse and my car started after another jump. I drove it home and pulled into the driveway just prior to very cold rain.

Though it was not pleasant to deal with, there’s always a silver lining to an unfortunate situation.  Here’s a few things we are grateful for:

1. We were not together and have two vehicles, so I could call Larry for help.
2. I had compensatory strategies that helped me remain calm and able to think.
3. I had my cell phone with me.
4. I was not far from home.
5. I was parked in a place where jumper cables could reach.
6. I was able to explain things to the manager who was understanding of my dilemma.
7. We were able to work together to find and correct the problem which was not too costly.
8. We made it back home prior to bad weather.

Be as prepared as possible for the unexpected and always plan ahead for any trip. You never know what challenge you may face when least expected. Compensatory strategies help compensate for what was lost as a result of the brain injury.
Beth has been posting to her blog since 2008 after acquiring an anoxic brain injury. You can visit her inspiring blog.

If you want to talk to someone about developing your own coping strategies your Occupational Therapist is a good place to start.

Download a Thinking and perception fact sheet .

Tai Chi is known as a healing art and a form of exercise that focuses on movement, posture and breathing. It is intended to improve the circulation of blood around the body and strengthen, relax, improve balance and ease tension.

Physio Chi is a modified form of Tai Chi developed by West Australian physiotherapist and Tai Chi instructor Moh Tapper.

Moh designed a gentler form of this exercise for her patients, including stroke survivors, so they could reap the benefits of the movements within their own physical capabilities. Physio Chi retains the principles and form of Tai Chi but is easier to learn and suitable for people who are not able to stand for long periods of time, something required by traditional forms of Tai Chi.

Moh’s special adaptation of Tai Chi takes the eastern approach to this ancient exercise and incorporates some western physiotherapeutic approaches. Moh explains that Physio Chi doesn’t involve pivoting or twisting on the feet or require bent knees for long periods of time. People who can’t stand at all can practice Moh’s Physio Chi in a sitting position. It can be used with a fit ball, done as a sitting exercise, in groups and even in water.

For more information click here.

Australia has a chronic shortage of specialised stroke rehabilitation services despite the fact that it is the second biggest cause of death and a leading cause of disability, a new report from the National Stroke Foundation has revealed.

Too many stroke survivors are being denied access to the specialised care essential to their recovery and ability to live independently - despite the fact that there are 60,000 strokes occurring in Australia every year, National Stroke Foundation CEO Dr Erin Lalor said.

Launching the National Stroke Audit of Rehabilitation Services in Melbourne on October 29, World Stroke Day, Dr Lalor said the report had shown there had been very little improvement in stroke rehabilitation in the last two years.
“Of the 60,000 strokes that occur in Australia every year, one-third of people affected will be left with a disability,” she said.

“Of those people who suffer a disability, 36 per cent will require inpatient rehabilitation – rehabilitation outside their home. This review of rehabilitation services clearly shows demand is dramatically outstripping supply.” On World Stroke Day, the National Stroke Foundation is spreading the message that one in six people will suffer a stroke in their lifetime – a stroke occurs every six seconds. Of those who survive their stroke, many will be left with a wide range of disabilities.

“The quality of their recovery depends on a variety of rehabilitation programs and treatments including speech and occupational therapy, physiotherapy and psychology services,” Dr Lalor said.

“Australia has very few specialised stroke rehabilitation units despite the fact that these units are proven to improve the chances of a good recovery.” The National Stroke Audit of Rehabilitation Services is the only program of its kind in Australia. It is designed to provide an overview of rehabilitation services for stroke and makes several important recommendations on stroke care based
on feedback from hospitals that reported almost 7,000 stroke admissions in 2009.

Among some of the difficulties the audit uncovered is the lack of ongoing training for health professionals; a lack of discharge and care plans for patients going home after stroke; and poor access to psychology services. ”Only 10 per cent of stroke patients surveyed in this audit were offered access to a psychologist for counselling,” Dr Lalor said. “Of those, 90 per cent accepted: a clear sign that stroke survivors need this service.”