1. health and fitness
2. therapy

Spejlneuroner og praksis
Jim Jensen
Ergoterapeut
FOTT Instruktør
Master i rehabilitering
Fagligt Netvæk i Ergoterapeutforeningen:
Senhjerneskade
19.11.2010
Baggrund
y 3 år i Tyskland fra 1996-1999
5 år på Kurhus, Dianalund
fra 1999-2004
2004 - nu på Hammel Neurocenter
y Med en enkelt afstikker til Neuroklinik i Århus
2005-2006
Inspiration:
Motivation og glæde
Kay Coombes
Theo Mulder / movement science
Patricia Davies: Skridt for skridt
Bernstein: Dexterity
Antonio Damasio: Descartes´ fejltagelse
Ramachandran: Phantoms of the brain
Studietur til University of Southern California / USC i
2007
USC
Aktivitetsvidenskab / occuptional science
Sanseintegration / Jean Ayres
Neurovidenskab / neuroscience
Damasio
og
Liza Aziz Zadeh
Spejlneuroner
Indholdspunkter
y Spejlneuronsystemet
y Spejlboks
y Spejlterapi
y Mental imagery
y Motor imagery
y Gruppeterapi
y Omgivelserne
y EEG studie - betydningsfulde stimuli i neurorehab.
Hjernen
100 billioner
neuroner som
hver indgår i 1000
– 10.000
forbindelser
Undersøgelser
y FMRI (Funktionel Magnetisk Ressonans Imaging)
y EEG (Elektro – EncephaloGrafi)
y TMS (Transkraniel Magnetisk Stimulation)
y PET (Positron Emission Tomografi)
Opdagelsen
Universitetet i Parma, 1989
(Fadiga, Rizzolatti)
- Single celle optagelser af neuroner I
område F5.
- Premotor area i makak aber.
-Neuroner koder for gribe bevægelser.
- Også neuronal fyring når aben kun
observerer forskeren håndtere objektet.
- Spændende nyt fund:
- Motor neuroner (involveret i udførelse af
handling) er også involveret i perceptionen
af andre menneskers motoriske handlinger.
Spejlneuroner
y Aktiveres når bevægelse udføres eller observeres.
(Gallese et al. 1996; Rizzolatti et al. 1996; Ferrari et al. 2003)
y Ligegyldig hvordan målet opnåes.
y
y
y
y
(Umiltàet al. 2008)
Aktiveres når bevægelsen kun kan ses fra hints
(Umiltàet al. 2001)
Aktiveres når bevægelsen kun kan høres
(Kohler et al. 2002)
Indeholder en ”abstrakt” repræsentation for handling.
Støtter en direkte form for handlings forståelse.
Menneske vs. abe
y Lokalisationen af spejlneuroner i mennesket er meget lig det
som er fundet i aber, men der er funktionelle forskelle.
1. Ved mennesker bliver SNS også aktiveret ved ikke–objekt
relaterede motoriske bevægelser, som også mimiske
handlinger.
2. Det menneskelige SNS er tunet til timingen af den motoriske
bevægelse, altså kodende den målrettethed der er over
bevægelsen men også de temporale aspekter af den
individuelle handling ledende til målet.
(Rizzolatti & Craighero 2004; Rizzolatti & Fabbri-Destro
2008).
Spejlneuroner og sansning
y Deling af taktile stimuli
y Deling af visuelle stimuli (spejlboks)
PMD
SPL
PM
V
Parietofrontale spejlneuron system
IPS
IPL
IFG
STS
Kortile områder relateret til parietofrontal spejl system responderer til
forskellige typer af motoriske handlinger. Gul indikerer transitive distale
bevægelser. Lilla: række bevægelser. Orange: Brug af redskaber. Grøn:
intransitive bevægelser. Blå: en del af superior temporale sulcus (STS) som
reagerer på bevægelser i overekstremiteten. IFG indikerer inferior frontal
gyrus; IPL, inferior parietal lobule; IPS, intraparietal sulcus; PMD, dorsal
premotor cortex; PMV, ventral premotor cortex; og SPL, superior
parietal lobule.
Spejlneuroner og emotioner
y Anatomical locations of the motor and somatosensory components
of simulation. (a) Lateral view of the human brain with the
location of the ventral premotor cortex (BA6/BA44) and the
inferior parietal lobule (IPL). (b) Lateral view showing the
location of the primary and secondary somatosensory cortex ...
y J. A. C. J. Bastiaansen, et al. Philos Trans R Soc Lond B Biol Sci.
2009 August 27;364(1528):2391-2404.
Spejlneuroner og emotioner
Anatomical locations of affective components of simulation.
(a) Sagittal view of a human brain with the location of the
anterior cingulate cortex (ACC). (b) Coronal view of a
human brain showing the location of the insula and the
amygdala.
From:
Philos Trans R Soc Lond B Biol Sci. 2009 August 27;
364(1528): 2391–2404.
Spejlneuroner og emotioner
y Et stort studie af mennesker med hjerneskade har vist at skader i
det højre sensomotoriske cortex (centreret omkring den mest
ventrale del af sensomotorisk cortex, hvor ansigtet er
repræsenteret) skader evnen til at erkende emotioner fra et
visuelt præsenteret ansigt.
(Adolphs et al. 2000).
y Aktivering af sensomotoriske repæsentationer af ansigtet er
afgørende for visuelt at kunne genkende følelser i andres ansigter.
V.S. Ramachandran
y “I predict that mirror neurons will do for psychology what
DNA did for biology: they will provide a unifying framework
and help explain a host of mental abilities that have hitherto
remained mysterious and inaccessible to experiments.”
y Imitation og empati.
y Lære bevægelser / handlinger
y og forstå hvad andre gør.
Udvikling gennem tiden
y Hjernen nuværende størrelse / form opnået for 3-400.000
y
y
y
y
y
y
år siden
For 100.000 år siden skete der et spring frem i ft.
Brug af ild
Brug af værktøj
Brug af huler/hytter
Sprog
Tese om udvikling/ modning af SNS (theory of the mind)
Neurorehabil Neural Repair. 2010 Jun;24(5):404-12. Epub 2010 Mar 5.
The mirror neuron system: a neural substrate for methods in stroke
rehabilitation.
Garrison KA, Winstein CJ, Aziz-Zadeh L.
Motor Behavior and Neurorehabilitation Laboratory, Division of Biokinesiology and
Physical Therapy, Brain and Creativity Institute, University of Southern California, Los
Angeles, CA 90089-9006, USA. [email protected]
Abstract
Mirror neurons found in the premotor and parietal cortex respond not only during
action execution, but also during observation of actions being performed by others.
Thus, the motor system may be activated without overt movement. Rehabilitation of
motor function after stroke is often challenging due to severity of impairment and poor
to absent voluntary movement ability. Methods in stroke rehabilitation based on the
mirror neuron system--action observation, motor imagery, and imitation--take
advantage of this opportunity to rebuild motor function despite impairments, as an
alternative or complement to physical therapy. Here the authors review research into
each condition of practice, and discuss the relevance of the mirror neuron system to
stroke recovery.
Fremtiden
y Hvad ligger foran os af nye, men også udfordrende
spørgsmål?
y Hvad er det at spejlneuroner gør for os?
y Hvilken forskel er der i funktionen på spejlneuronerne i de
forskellige hjerneområder?
y Hvordan interagerer spejlneuroner i de forskellige
hjerneområder med hinanden?
y Hvordan bliver handlinger en del af os eller andre, og hvilke
roller spiller anti – neuroner i denne funktion?
Terapi – individuel / grupper
y Spejling i forhold til andre medpatienter / raske.
y Fordele – ulemper.
y Rollemodeller – Patient / terapeut.
y Brug af følelser – relationer.
y Eksemplificere bevægelser.
y Før – under – efter.
Omgivelser
y Mulighed for spejling
y Af andre
y Af sig selv
y Mulighed for aktiviteter
y Billeder af mennesker i aktivitet
Motor imagery
y Arch Phys Med Rehabil. 2003 Jul;84(7):1090-2: Performance of
the paretic limb improved after the imagery intervention,
indicated by increases in assessment scores and functionality and
decreases in movement times. The improvements over baseline
performance remained stable over a 3-month period (8 subjects)
y Neuroimage. 2007;36 Suppl 2:T164-73 : A significant
improvement of motor functions in the course of a 4-week
treatment, as compared to the stable pre-treatment baseline, and
compared with a control group have been found. The
improvement lasted for at least 8 weeks after the end of the
intervention (8 subjects)
Mental imagery
Motor recovery
y Lancet Neurol. 2009 Aug;8(8):741-54.
y Motor recovery after stroke: a systematic review.
y Langhorne P, Coupar F, Pollock A.
y Stroke Therapy Evaluation Programme, Academic Section of Geriatric Medicine, Cardiovascular
and Medical Sciences Division, Royal Infirmary, Glasgow, UK. [email protected]
y Abstract
y Loss of functional movement is a common consequence of stroke for which a wide range of
interventions has been developed. In this Review, we aimed to provide an overview of the available
evidence on interventions for motor recovery after stroke through the evaluation of systematic
reviews, supplemented by recent randomised controlled trials. Most trials were small and had
some design limitations. Improvements in recovery of arm function were seen for constraintinduced movement therapy, electromyographic biofeedback, mental practice with motor imagery,
and robotics. Improvements in transfer ability or balance were seen with repetitive task training,
biofeedback, and training with a moving platform. Physical fitness training, high-intensity therapy
(usually physiotherapy), and repetitive task training improved walking speed. Although the existing
evidence is limited by poor trial designs, some treatments do show promise for improving motor
recovery, particularly those that have focused on high-intensity and repetitive task-specific practice.
Spejlboks
y Ramachandran, 1998 (phantoms of the brain)
Baggrund for spejlboks
y Hjernens plasticitet som bl.a. er set ved amputationer
y Fantomoplevelser og smerte.
y Refleksdystrofi / smerte (McCabe et al) og spejlterapi.
y Hemiplegi.
Sensomotorisk cortex
Sensoriske proportioner
Spejlterapi
y Neurorehabil Neural Repair. 2010 Nov 4. [Epub ahead of print]
y Motor Recovery and Cortical Reorganization After Mirror Therapy in Chronic
Stroke Patients: A Phase II Randomized Controlled Trial.
y Michielsen ME, Selles RW, van der Geest JN, Eckhardt M, Yavuzer G, Stam HJ, Smits M, Ribbers
GM, Bussmann JB.
y Abstract
y OBJECTIVE: To evaluate for any clinical effects of home-based mirror therapy and subsequent
cortical reorganization in patients with chronic stroke with moderate upper extremity paresis.
y METHODS: A total of 40 chronic stroke patients (mean time post .onset, 3.9 years) were
randomly assigned to the mirror group (n = 20) or the control group (n = 20) and then joined a 6week training program. Both groups trained once a week under supervision of a physiotherapist at
the rehabilitation center and practiced at home 1 hour daily, 5 times a week. The primary outcome
measure was the Fugl-Meyer motor assessment (FMA). The grip force, spasticity, pain, dexterity,
hand-use in daily life, and quality of life at baseline-posttreatment and at 6 months-were all
measured by a blinded assessor. Changes in neural activation patterns were assessed with functional
magnetic resonance imaging (fMRI) at baseline and posttreatment in an available subgroup (mirror,
12; control, 9).
y RESULTS: Posttreatment, the FMA improved more in the mirror than in the control group (3.6 ±
1.5, P < .05), but this improvement did not persist at follow-up. No changes were found on the
other outcome measures (all Ps > .05). fMRI results showed a shift in activation balance within the
primary motor cortex toward the affected hemisphere in the mirror group only (weighted laterality
index difference 0.40 ± 0.39, P < .05).
y CONCLUSION: This phase II trial showed some effectiveness for mirror therapy in chronic stroke
patients and is the first to associate mirror therapy with cortical reorganization. Future research has
to determine the optimum practice intensity and duration for improvements to persist and
generalize to other functional domains.
y
y
y
y
y
y
y
y
y
Disabil Rehabil. 2009;31(26):2135-49.
Systematic review of the effectiveness of mirror therapy in upper extremity
function.
Ezendam D, Bongers RM, Jannink MJ.
Center for Human Movement Sciences, University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands.
Abstract
PURPOSE: This review gives an overview of the current state of research regarding the
effectiveness of mirror therapy in upper extremity function.
METHOD: A systematic literature search was performed to identify studies concerning
mirror therapy in upper extremity. The included journal articles were reviewed
according to a structured diagram and the methodological quality was assessed.
RESULTS: Fifteen studies were identified and reviewed. Five different patient
categories were studied: two studies focussed on mirror therapy after an amputation of
the upper limb, five studies focussed on mirror therapy after stroke, five studies focussed
on mirror therapy with complex regional pain syndrome type 1 (CRPS1) patients, one
study on mirror therapy with complex regional pain syndrome type 2 (CRPS2) and two
studies focussed on mirror therapy after hand surgery other than amputation.
CONCLUSIONS: Most of the evidence for mirror therapy is from studies with weak
methodological quality. The present review showed a trend that mirror therapy is
effective in upper limb treatment of stroke patients and patients with CRPS, whereas the
effectiveness in other patient groups has yet to be determined.