Provider & Clinician eNews
January 2010
 
 

The Education Section

 

 

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In this eNews:
  • CVA Case Study
  • Supporting Research
  • New Intermediate Webinars
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CVA Patient Returns to Work After IM
by improving vigilance, simultaneous capacity, and use of compensatory memory strategies

Eileen Stack McLaughlin, MA CCC- SLP, HealthSouth Florence- Florence, SC

Jason is a 33 year old independent male with degrees in Business and Finance working at a loan company. In November 2007 he was admitted to the ER for mental status changes and confusion. Immediately he underwent an angiography where a four vessel cerebral arteriogram was performed to repair an AVM. (Arteriovenous Malformation). Fortunately the arteriogram performed resulted in a negative AVM aneurysm but instead Jason was determined to have a basal ganglia hemorrhage.

Jason’s initial assessment cognitively placed him in the severe range for memory. Although he was able to state orientation information he had difficultly with short term and episodic information. He was first admitted to the hospital November 16, 2007 then thought to be stable for rehabilitation 5 days later. Upon admission to rehab he demonstrated decreased concentration, confusion and decreased ability to stay on task. He was impulsive and appeared to become more confused at night. He remained in inpatient rehab for 16 days and was discharged for outpatient services. He was discharged with CVA secondary to ventricular hemorrhage, history of hypertension and post stroke confusion with short term memory deficits.

Jason received outpatient services for 16 visits for cognitive therapy and 12 visits each of physical and occupational therapy. He completed a driver performance test and scored in the average range. He wanted to get back to work as a finance counselor 2 months after his hemmorage.

Jason described his re-acquaintance with his projects and file system on his desk when he resumed his job duties. His coworkers noticed his difficulty recalling messages and meetings. His ability to take verbal messages and recall phone numbers and take notes were deficient. The coworkers noticed a significant difference in his job performance and described a desk full of sticky notes as reminders of phone numbers and follow up on clients.

After returning to work Jason’s Executive Finance Office recommended that he return for more therapy. He returned to outpatient therapy and received cognitive therapy with the use of Interactive Metronome.

Jason described himself as realizing he had attention deficit in high school but worked through it with strategies while at Penn State University. After reevaluating his executive functioning and attention shifting, Jason’s therapy focused on increasing vigilance. He continued for 21 sessions three times a week focusing on recalling names of familiar people, task vigilance, improving simultaneous capacity and use of compensatory memory strategies.

He was unable to recall 5 digits or 4 unrelated words immediately. Shift of attention by recalling and reversing 4 digits was also impaired. He was only 90% accurate to alternate attention with number and letter tasks.

With the use of the IM his vigilance improved and became more proficient. He was required to pick up blocks in a basket by alternating red and blue blocks while performing an IM foot exercise at the same time. During other exercises he was required to perform IM exercises with both hands or both feet while at the same time performing complex verbal tasks. For example he would be shown a playing card and be required to say out loud either a different suit or a different number from the one shown without interrupting his focus on his IM exercises. Other automatic verbal responses were used such as counting backwards while he performed a rhythmic IM exercise. Balance was often addressed as he was positioned prone to perform an activity to match the IM Reference Tone with a hand movement on the foot pad. Overall simultaneous capacity improved.

Upon reassessment his verbal attention improved and Jason could:

  • immediately recall 5 numbers consistently.

  • shift attention and reverse 5 numbers.

  • recall a 12-13 word sentence.

  • easily recall 4 and sometimes 5 unrelated words.

Jason resumed his work schedule and returned to his job in Finance stating how much more focused and successful he was.

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Study shows new brain connections form rapidly during motor learning

SANTA CRUZ, CA--New connections begin to form between brain cells almost immediately as animals learn a new task, according to a study published this week in Nature. Led by researchers at the University of California, Santa Cruz, the study involved detailed observations of the rewiring processes that take place in the brain during motor learning.

The researchers studied mice as they were trained to reach through a slot to get a seed. They observed rapid growth of structures that form connections (called synapses) between nerve cells in the motor cortex, the brain layer that controls muscle movements.

"We found very quick and robust synapse formation almost immediately, within one hour of the start of training," said Yi Zuo, assistant professor of molecular, cell and developmental biology at UCSC.

Zuo's team observed the formation of structures called "dendritic spines" that grow on pyramidal neurons in the motor cortex. The dendritic spines form synapses with other nerve cells. At those synapses, the pyramidal neurons receive input from other brain regions involved in motor memories and muscle movements. The researchers found that growth of new dendritic spines was followed by selective elimination of pre-existing spines, so that the overall density of spines returned to the original level.

"It's a remodeling process in which the synapses that form during learning become consolidated, while other synapses are lost," Zuo said. "Motor learning makes a permanent mark in the brain. When you learn to ride a bicycle, once the motor memory is formed, you don't forget. The same is true when a mouse learns a new motor skill; the animal learns how to do it and never forgets."

Understanding the basis for such long-lasting memories is an important goal for neuroscientists, with implications for efforts to help patients recover abilities lost due to stroke or other injuries.

"We initiated the motor learning studies to understand the process that takes place after a stroke, when patients have to relearn how to do certain things. We want to find out if there are things we can do to speed up the recovery process," Zuo said.

The lead authors of the Nature paper, Tonghui Xu and Xinzhu Yu, are a postdoctoral researcher and doctoral student, respectively, in Zuo's lab at UCSC. Coauthors include Andrew Perlik, Willie Tobin, and Jonathan Zweig of UCSC and Kelly Tennant and Theresa Jones of the University of Texas, Austin.

The study used mice that had been genetically altered to make a fluorescent protein within certain neurons in the brain. The researchers were then able to use a special microscopy technique (two-photon microscopy) to obtain clear images of those neurons near the surface of the brain. The noninvasive imaging technique enabled them to view changes in individual brain cells of the mice before, during, and after the mice were trained in the seed-reaching task.

"We were able to follow the same synapses over time, which had not been done before in a motor learning study," Zuo said. "We showed that structural changes occur in the brain at a much earlier stage than people had believed."

Results from the study suggested that the newly formed dendritic spines are initially unstable and undergo a prolonged selection process during the course of training before being converted into stable synapses.

When previously trained mice were reintroduced to the reaching task four months later, their skill at the task remained high, and images of their brains did not show increased spine formation. When previously trained mice were taught a new skill, however, they showed enhanced spine formation and elimination similar to that seen during the initial training. Furthermore, spines that had formed during the initial training persisted after the remodeling process that accompanied the learning of a new task.

These findings suggest that different motor behaviors are stored using different sets of synapses in the brain, Zuo said. One of the questions she would like to explore in future studies is how these findings apply to different types of learning.

"In China, where I grew up, we memorize a lot in school. What are the changes that take place in the brain during learning and memorizing, and what are the best ways to consolidate those memories? We don't really know the best way to learn and memorize," she said.

Contact: Tim Stephens
stephens@ucsc.edu
831-459-2495
University of California - Santa Cruz
Source:Eurekalert

 

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