Keys to Upper Extremity Therapy Success
Recovery of upper extremity movement after an event such as a stroke is a skill relearning process.1,2 This means that the stroke survivor must relearn how to move their arm because the stroke damaged the brain’s ability to control the movement and coordination of the arm. For several decades neuroscientists and rehabilitation scientists have conducted studies to determine what critical elements need to be part of the of stroke rehabilitation process to promote skill relearning.3-5 Two of the critical elements that are shown to be important are 1) extended practice6 and 2) progression of difficulty.3,7
Duck Duck Punch was designed as a game that utilizes these elements to promote help people improve reaching ability after stroke.
1) Extended therapy practice
Extended practice critical to relearn motor skills
Whether you are learning to play a sport, learning a new instrument, or learning to reuse your arm after a stroke, the amount of time spent practicing the skill is critically important for improving that skill11. Repetition has been shown to be related to improved motor recovery post stroke8. Animal models of stroke recovery show that thousands of repetitions of movement are needed to facilitate recovery9. Similar results have been found in humans8,10.
Recovr tools support extended therapy practice
The Recovr Rehabilitation System was designed provide the player with the opportunity to practice reaching with their affected arm in a fun and engaging way. The game encourages players to reach for targets to improve their score, but the player controls the pace of the game so each individual can play at a pace that is comfortable for them and that is based on their therapist’s plan of care.
2) Progression of difficulty
Repetition + The Appropriate Level of Challenge
Although repeated practice is helpful in improving skill,12 there is a growing understanding that repetition alone is not enough13. To improve skill you need to practice continually harder tasks. Practicing the same task over and over does not lead to improved recovery of movement after stroke.14,15 Rehabilitation research supports the idea that post-stroke motor skill relearning may occur when a person repeatedly practices movements at the “just-right challenge level”.16 Movement practiced at the just-right level of challenge means that the task should not be too easy or too hard.
Not too easy, not too hard
If a person can successfully do the task every time, then the task is too easy and they are just repeating something they can already do. If a person fails at every attempt then the task is likely too hard. However, a combination of errors and success on the other hand fosters skill relearning because it enables a person to self-evaluate his/her movement strategies, make modifications and seek a new movement strategy that will result in greater success17-19. During therapy, occupational or physical therapists modify the difficulty level of the activities to assure the just-right challenge level.
Recovr tools supports repetition at just the right level of challenge
The Recovr Rehabilitation System was specifically designed so that the player or therapist can adjust game difficulty so that it matches the player’s unique level of movement ability.
- Carr J, Shepherd R. A Motor Learning Model for Stroke. 2nd ed. Oxford: Buterworth Heinemann; 1987.
- Krakauer JW. Motor learning: its relevance to stroke recovery and neurorehabilitation. Current opinion in neurology. 2006;19(1):84-90.
- Nielsen JB, Willerslev-Olsen M, Christiansen L, Lundbye-Jensen J, Lorentzen J. Science-Based Neurorehabilitation: Recommendations for Neurorehabilitation From Basic Science. Journal of Motor Behavior. 2015;47(1):7-17.
- Page SJ, Boe S, Levine P. What are the “ingredients” of modified constraint-induced therapy? An evidence-based review, recipe, and recommendations. Restor Neurol Neurosci. 2013;31(3):299-309.
- Kitago T, Krakauer JW. Motor learning principles for neurorehabilitation. Handbook of clinical neurology. 2013;110:93-103.
- Wolf SL, Blanton S, Baer H, Breshears J, Butler AJ. Repetitive task practice: a critical review of constraint-induced movement therapy in stroke. Neurology. 2002;8(6):325-338.
- Jones TA, Adkins DL. Motor System Reorganization After Stroke: Stimulating and Training Toward Perfection. Physiology. 2015;30(5):358-370.
- Lohse KR, Lang CE, Boyd LA. Is more better? Using metadata to explore dose-response relationships in stroke rehabilitation. Stroke; a journal of cerebral circulation. 2014;45(7):2053-2058.
- Bell JA, Wolke ML, Ortez RC, Jones TA, Kerr AL. Training Intensity Affects Motor Rehabilitation Efficacy Following Unilateral Ischemic Insult of the Sensorimotor Cortex in C57BL/6 Mice. Neurorehabilitation and neural repair. 2014.
- Birkenmeier RL, Prager EM, Lang CE. Translating animal doses of task-specific training to people with chronic stroke in 1-hour therapy sessions: a proof-of-concept study. Neurorehabilitation and neural repair. 2010;24(7):620-635.
- Kleim JA. Neural Plasticity: Foundation for Neurorehabilitation. TANAS Publishing; 2012.
- Nudo RJ, Milliken GW. Reorganization of movement representations in primary motor cortex following focal ischemic infarcts in adult squirrel monkeys. J Neurophysiol. 1996;75(5):2144-2149.
- Lee TD, Swanson LR, Hall AL. What is repeated in a repetition? Effects of practice conditions on motor skill acquisition. Physical therapy. 1991;71(2):150-156.
- Plautz EJ, Milliken GW, Nudo RJ. Effects of repetitive motor training on movement representations in adult squirrel monkeys: role of use versus learning. Neurobiol Learn Mem. 2000;74(1):27-55.
- Adkins DL, Boychuk J, Remple MS, Kleim JA. Motor training induces experience-specific patterns of plasticity across motor cortex and spinal cord. J Appl Physiol. 2006;101(6):1776-1782.
- Guadagnoli MA, Lee TD. Challenge point: a framework for conceptualizing the effects of various practice conditions in motor learning. J Mot Behav. 2004;36(2):212-224.
- Popa LS, Streng ML, Hewitt AL, Ebner TJ. The Errors of Our Ways: Understanding Error Representations in Cerebellar-Dependent Motor Learning. Cerebellum (London, England). 2015.
- Herzfeld DJ, Vaswani PA, Marko MK, Shadmehr R. A memory of errors in sensorimotor learning. Science (New York, N.Y.). 2014;345(6202):1349-1353.
- Diedrichsen J, White O, Newman D, Lally N. Use-dependent and error-based learning of motor behaviors. The Journal of neuroscience : the official journal of the Society for Neuroscience. 2010;30(15):5159-5166.