Decreasing Fear of Falling in Chronic Stroke Survivors Through Cognitive Behavior Therapy and Task-Oriented Training

I would think that perturbation training would be much better because you would be able to recover from balance problems and thus prevent the fall.  But I know nothing, I'm not medically trained. This falls under the same category that you learn faster from your mistakes than from practicing perfection. 

Decreasing Fear of Falling in Chronic Stroke Survivors Through Cognitive Behavior Therapy and Task-Oriented Training

Tai-Wa Liu

,

Gabriel Y.F. Ng

,

Raymond C.K. Chung

,

Shamay S.M. Ng

Originally published7 Dec 2018Stroke. 2018;0:STROKEAHA.118.022406

Abstract

Background and Purpose—

Research has shown that balance training is effective for reducing the fear of falling in individuals with a history of stroke. In this study, we evaluated (1) whether cognitive behavior therapy could augment the beneficial effects of task-oriented balance training (TOBT) in reducing the fear of falling in chronic stroke survivors and (2) whether it could, in turn, reduce fear-avoidance behavior and improve related health outcomes.

Methods—

Eighty-nine cognitively intact subjects with mildly impaired balance ability were randomized into the following 2 groups that underwent 90-minutes interventions 2 days per week for 8 weeks: (1) cognitive behavior therapy + TOBT or (2) general health education + TOBT (control). The primary outcome was the fear of falling, and the secondary outcomes were fear-avoidance behavior, balance, fall risk, independent daily living, community integration, and health-related quality of life. The outcomes were assessed at baseline, after 4 and 8 weeks of intervention, and 3 and 12 months after completing the intervention.

Results—

Eighty-two subjects completed the intervention and follow-up assessments. From postintervention to 12 months after completing the intervention, the cognitive behavior therapy + TOBT participants reported greater reduction in the fear of falling and fear-avoidance behavior and greater improvements in balance and independent daily living than the general health education + TOBT participants.

Conclusions—

Cognitive behavior therapy should be considered as an adjuvant therapy to standard physiotherapy for cognitively intact individuals(So you cherry picked participants?, I expect recovery for all. Yes that will be more difficult but leaders tackle difficult problems. Are you a mouse or a leader?)  with a history of stroke.

Clinical Trial Registration—

URL: http://clinicaltrials.gov. Unique identifier: NCT02937532

Using High Repetitions in Stroke Rehab

Finally someone putting out a number of repetitions for neuroplasticity to take hold. But notice the caveat, challenging, and I'm sure your therapist will want you to do them perfectly. Even though you learn faster by correcting your mistakes or varying your routine. I would need spasticity fixed before I could even attempt any of these. http://www.stroke-rehab.com/support-files/strokerecoverytipsseptember2016.pdf A word you hear often in stroke rehabilitation is neuroplasticity. Neuroplasticity in simple terms basically refers to the brain’s ability to rewire itself and create new connections. Repetitive practice of a task has been shown to make changes in the human cortex. For example, practicing a task such as playing the piano can increase the finger representation in the motor cortex. On the other hand, lack of movement of a muscle can result in decreases in representation of the muscle in the motor cortex. If parts of the brain are damaged that control cer- tain muscle movements, sometimes neuroplasticity can allow for other areas of the brain to take over. Research has shown that in order to help foster these neuroplastic changes, it is important to have high repetition practice. Animal studies have shown that 400-600 repetitions of a challenging task are needed per day to make changes in the brain. Therapists at most centers do not have a patient perform anywhere near this number of repetitions of a task. Random performance of a task such as practicing a few hundred reps one or two days a week will not result in very noticeable changes, but practicing a task for high reps daily over several weeks would result in much more noticeable im- provement. Unfortunately, patients often only go to therapy a couple of times a week and do not perform a high number of repetitions of a challenging task. If you want to see better results with an activity, it is recommended to incorporate high reps of the task daily for several weeks. The type of task attempted will be different for each stroke patient depending on their impairment and capabilities. Trying to type may be appropriate for one patient needing to work on fine motor control whereas trying to slide a washcloth across a table may be appropriate for another who lacks fine motor movement. If you pick a task that is easy to perform, then you will not stimulate the brain in the same way as if you pick a more complicated task for yourself. One task may be too easy for one patient and too complicated for another so you have to adjust the task/activity to your abilities. Some ideas for tasks are listed below (tasks can be done with adaptive equipment if needed):  
Pushing piano keys 
Typing 
Clapping Not possible due to spasticity 
Rolling dice 
Catching 
Throwing
Moving or sliding an object 
Reach/grasp/release of an object Not possible due to spasticity
Holding an object between both hands and lifting it.
Rolling, kicking or bouncing a ball

Turning off a light switch

Dot to dot activity

Writing

Folding a washcloth

Painting strokes (can attach brush to hand with an assistive device if can’t grip)

Using a tool

Bringing a utensil to the mouth

Picking up a cup

Playing a finger app on the phone (e.g. Cut the Rope, Fruit Ninja)

Trying to hit a balloon.

Playing a board game such as Simon.

Opening a container

Turning a page in a book or magazine

If you look at the above list of activities and feel like they are too hard be-

cause you have severe hemiplegia or paralysis, then try to work what move-

ment you do have. Remember you can also use adaptive equipment to help

such as a Grip Aid Glove, a universal cuff, a keyboard aid, etc. if you don’t have finger movement. Easier tasks to start with might be placing your paralyzed hand on top of a ball (e.g. a basketball or soccer ball) and try to slightly roll the ball a few inches side to side or trying to use the arm to push a light object on a table.

For training to be most effective, a task should be meaningful and engaging to the patient and be associated with a goal. You should be able to adapt and progress the task as well. For example, if the goal was to shoot a basketball into a hoop, you could start as mentioned above by first just placing the affected hand on a ball and rolling it. You could then progress to holding the ball between two hands and lifting it, then lifting it higher (adapting holds as necessary), throwing the ball down, throwing the ball out, throwing the ball up, and throwing the ball into different hoops of different heights. In my opinion, tasks should be chosen by the patient to increase motivation. For example, I treated a patient who liked to shoot guns and his goal was to be able to hold and pull the trigger of a gun. He was very motivated to relearn this task.

We weren’t able to use a real gun in our clinic, but we practiced movements with other materials, and he practiced with an unloaded gun at home. I would have never chosen this task as a therapist, however, by talking with the patient, I found something that motivated him and sparked his interest and increased his participation in therapy.

If you have no arm movement, then mirror therapy may be an alternative.

In mirror therapy, you watch the reflection of the non-affected limb in a mirror and your brain perceives the reflection as your affected limb. By watching repetitive movement of the working limb in the mirror, it has been shown in some studies that new connections can be made for the paralyzed side because the brain perceives that the paralyzed side is working (even though it is actually only a reflection of the non-affected arm working).

Remember, doing therapy a couple of days a week for a short period is not enough. To get the most out of your rehabilitation, you should be working at home daily. Make sure to choose somewhat challenging tasks that you are motivated to do, and that repetition is key to achieving your goals.

Scientists have found a way to help you learn new skills twice as fast

Putting this together with

Why memories of mistakes may speed up learning

and your therapist should have a decent protocol for you to learn all those skills you lost as part of your stroke.

Scientists have found a way to help you learn new skills twice as fast

But I doubt any therapist in the world will do this. Our fucking failures of stroke associations certainly will not.
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The key to learning a new motor skill - such as playing the piano or mastering a new sport - isn't necessarily how many hours you spend practising, but the way you practise, according to new research. Scientists have found that by subtly varying your training, you can keep your brain more active throughout the learning process, and halve the time it takes to get up to scratch.
The research goes somewhat against the old assumption that simply repeating a motor skill over and over again - for example, practising scales on the piano or playing the same level on your game over and over again - was the best way to master it. Instead, it turns out there might be a quicker (and more enjoyable) way to level up.
"What we found is if you practise a slightly modified version of a task you want to master, you actually learn more and faster than if you just keep practising the exact same thing multiple times in a row," said lead researcher Pablo Celnik, from Johns Hopkins University.
The researchers figured this out by getting 86 volunteers to learn to a new skill - moving a cursor on a computer screen by squeezing a small device, instead of using a mouse.
The volunteers were split into three groups, and each spent 45 minutes practising this. Six hours later, one of the groups was asked to repeat the same training exercise again, while another group performed a slightly different version that required different squeezing force to move the cursor.
The third group only completed the first training session, so they could act as a control.
At the end of the training period, everyone was tested on how accurately and quickly they could perform the new skill, and predictably, the control group did the worst after their one training session. But the surprise was that the group that had repeated the original training session actually did worse on the test compared to those who had mixed things up and trained in new areas - in fact, the group that modified their training did twice as well as those who'd repeated the original skill.
So how does that work? The researchers believe it's due to something called reconsolidation, which is a process whereby existing memories are recalled and modified with new knowledge. It's long been suggested that reconsolidation could help to strengthen motor skills, but this is one of the first experiments to test that hypothesis.
This is also why the researchers gave the participants a 6-hour gap between training session - earlier neurological research has shown that's how long it takes for our memories to reconsolidate.
"Our results are important because little was known before about how reconsolidation works in relation to motor skill development. This shows how simple manipulations during training can lead to more rapid and larger motor skill gains because of reconsolidation," said Celnik. "The goal is to develop novel behavioural interventions and training schedules that give people more improvement for the same amount of practise time."
Although there's benefit in mixing things up with your practise, Celnik said the key was adjusting things subtly - for example, adjusting the size or weight of a baseball bat, tennis racket or soccer ball in between practise sessions.
"If you make the altered task too different, people do not get the gain we observed during reconsolidation. The modification between sessions needs to be subtle," he added.
Although these results are pretty exciting, this study has only tested one particular skill-set, and so further research needs to be done to confirm the findings. But if true, finding an easy way to double the rate at which people can learn new motor skills would be a huge deal.
In addition to helping us all tick off our 2016 resolutions in half the time - hello, finally mastering Debussy's Clair de Lune - there are more altruistic impacts of the research. The research has "strong implications for rehabilitation", the authors write in Current Biology. For example, the new information could help amputees learn to use their prostheses faster, or speed up the recover of people who've suffered from spinal injuries or stroke.
We're pretty keen to try it out.

Learning from your mistakes: not in the case of brain damage

The followup that is required to be able to use this after stroke. What area of damage would require use of Errorless learning rather than learning from your errors?  A very simple question that will never be answered under the current stroke non leadership.
http://www.alphagalileo.org/ViewItem.aspx?ItemId=159464&CultureCode=en

Do people learn from their mistakes? This question is often a subject of discussion at rehabilitation centres. For people with memory problems preventing mistakes is a better learning strategy. Neuropsychologist Dirk Bertens has now demonstrated that ‘errorless learning’ also works with people with non-congenital brain damage. He will be awarded a PhD for his research by Radboud University on 8 January 2016.
A significant proportion of people with brain damage that has been caused by a stroke or accident suffer from disrupted executive functions: for them, actions that consist of several steps and require planning are difficult. That causes problems because virtually all of our everyday actions consist of several steps, even holding a normal conversation. Such patients therefore receive training to relearn these everyday tasks.
Errorless-learning doves
In ‘errorless learning’ you prevent mistakes from occurring by dividing the target to be achieved into steps and explaining those with extensive descriptions, examples, visual instructions and especially pauses in between the steps. Errorless learning originates from research into doves. The American psychologist Herbert Terrace taught doves to peck at a red button but not a green one. As the task was slowly made more complex – first the doves only learned the difference between the colours red and green and then the difference between the red and the green button – the doves rarely made mistakes in the last, most difficult task.
Beekeeping and Internet banking
In people the principle has so far been investigated among individuals with memory disorders, such as dementia, and for them it appears to be a successful approach.
Dirk Bertens investigated the effect of the training on sixty people with non-congenital brain damage who had problems with planning. The participants were allowed to choose two everyday tasks to train on. Bertens: “They chose tasks such as Internet banking or making lasagne. One participant was a beekeeper and chose to practise investigating his beehives and subsequently filling in a report. So that is what we did.”
Neuropsychologist Dirk Bertens during the inspection of one of the participant’s beehives.
Error versus errorless
Half of the group received a ‘standard’ trial-and-error training and the other half practised with an errorless learning method. Whereas the first group were given the space to make errors and to subsequently correct these, the second group received extensive instructions both before and during the realisation of the task. “We briefly paused between each intermediate step to check if things were still going well. The participants found it particularly difficult to pause for such an evaluation moment. However, after eight training sessions they realised the tasks better than the participants in the control group.”
Both the trainers and the participants saw a clear improvement after the errorless training sessions. “I would like to implement the principle of errorless learning in rehabilitation centres throughout the Netherlands,” says Bertens. “With this implementation it can be examined whether there are even more patient groups who could benefit from this approach, for example individuals with congenital learning disorders or learning disabilities.”

AllTrials calls for all past and present clinical trials to be registered and their full methods and summary results reported.

This is where our stroke associations could finally do some good, they could join this and get all stroke trials published. This statement from Dr. Michael Tymianski, of the Toronto Western Hospital Research Institute in Canada who talked about 1000+ failed neuroprotective drugs years ago. We should know exactly what those 1000+ trials were trying to accomplish and why they failed. If we don't learn from our failures we are doomed to repeat them.

“We learn from failure, not from success!”
― Bram Stoker, Dracula  ?

“Smart people learn from their mistakes. But the real sharp ones learn from the mistakes of others.”
― Brandon Mull, Fablehaven  

“I make mistakes like the next man. In fact, being--forgive me--rather cleverer than most men, my mistakes tend to be correspondingly huger.”
― J.K. Rowling, Harry Potter and the Half-Blood Prince  
  
“In school we learn that mistakes are bad, and we are punished for making them. Yet, if you look at the way humans are designed to learn, we learn by making mistakes. We learn to walk by falling down. If we never fell down, we would never walk.” (This is not the way we relearn to walk after a stroke)
― Robert T. Kiyosaki, Rich Dad, Poor Dad  
“Your most unhappy customers are your greatest source of learning.”
― Bill Gates 
(And I am a damned unhappy survivor, what are the stroke associations doing to learn from me?) 
   
http://www.alltrials.net/find-out-more/all-trials/

Why memories of mistakes may speed up learning

Does this mean our therapists should be forcing us to make mistakes so we can work in those “prediction errors”?
http://scopeblog.stanford.edu/2014/08/14/why-memories-of-mistakes-may-speed-up-learning/

“prediction errors,”

“prediction errors,”

“prediction errors,”

“prediction errors,”

“prediction errors,”

“prediction errors,”