This document provides an overview of Andrew Gordon's research focusing on neural mechanisms underlying movement disorders, motor learning and control, and development and testing of rehabilitation protocols. Some key areas of Gordon's research include the neural basis of movement representations, sensory motor control, motor planning, learning, and neural correlates of rehabilitation. The document also summarizes research on impaired hand function in hemiplegic cerebral palsy, including sensory impairments, impaired movement execution, anticipatory control, development of function, effects of intensive practice, involvement of both upper extremities, impaired bimanual coordination, and the role of the less affected hand in rehabilitation.

1. Andrew M. Gordon, Ph.D.
IPRC

3. Overview of my research
Neural
Development and
Systems mechanisms
neuroscience, testing of rehabilitation
underlying
motor learning & protocols
movement
control
disorders
•Neural basis of movement •Sensory motor control •Evidence-based practice
representations •Motor planning •Role of treatment intensity
•Sensorimotor •Digit individuation •Dosing & ingredients
transformation underlying •Learning •Treatment specificity
UE movement
•Neural correlates of rehab

4. The human hand: Basic science and clinical applications
• The hand is fundamental to
sensorimotor development
• The sensory machinery of the
hand allows to extract detailed
knowledge about objects we
interact with
• The unique versatility of the
hand motor system enables
highly dexterous control of a
large repertoire of movements

5. Impaired Hand Function in Hemiplegic CP
Symptoms Include:
Abnormal muscle tone
Posturing into wrist flexion, ulnar deviation,
elbow flexion and shoulder rotation
Reduced strength
Tactile and proprioceptive disturbances
Developmental non-use
Impaired motor planning
Impaired motor learning

6. Corticospinal (CST) tract integrity is predictive
of hand function
Bleyenheuft et al. 2007

7. Timing of CNS damage and CST innervation
pattern affect dexterity
Holmstrom et al. (2010)
Staudt et al. (2004)

8. Hand function in hemiplegic CP
•Sensory impairments
•Impaired movement execution.

9. Impaired digit individuation
TD
T T
II= .90 II= .69
I I
M M
R R
L L
T T
I I
II= .88 II= .47
M M
R R
L
L
T T
I I
M M
II= .80 R
R II= .58
L L
T T
I I
M M
R II= .86 R
II= .23
L L
T T
I
I M
M R II= .22
R L
II= .96 2c m
L
Petra & Gordon (In Preparation) 3 sec s

10. Impaired digit individuation
Individuation Index T D non-dominant
Average Perform ance T D dominant
1
HC P involved
0.9
HC P non-involved
0.8
Individuation Index
0.7
0.6
0.5
0.4
where IIj is the individuation index of the
0.3
instructed jth digit while Nij is the normalized 0.2
displacement of the ith digit during the jth 0.1
instructed movement and n is the number of 0
thumb index middle ring little
digits (n=5).
Digit
T D non-dominant
Stationarity Index
Average Perform ance T D dominant
1 HC P involved
0.9 HC P non-involved
0.8
Stationarity Index
0.7
0.6
0.5
0.4
where SIi is the stationarity index for a non-
0.3
instructed digit Nij is the normalized 3D resultant 0.2
displacement of the ith digit during the jth 0.1
instructed movements and m is the number of 0
instructed movements (m=5). thumb index middle ring little
Digit
Petra & Gordon, In Preparation

11. Impaired precision grip
Eliasson et al. (1991)

12. Hand function in hemiplegic CP
•Sensory impairments
•Impaired movement execution.
•Impaired anticipatory control (Eliasson et al. 1992; Gordon
& Duff 1999).

13. - 400 gm
--- 200 gm
Gordon & Duff (1999a)

14. Impaired anticipatory fingertip force coupling during
gait
Prabhu et al. (2011)

15. Visuomotor efficiency (VME) index
Summarizes information about the extent to which hand posture discriminates towards object. Computed using
all measured joints of each digit at 5% intervals during reach-to-grasp.
• Step 1
Discriminant analysis to
determine if the hand postures
are reliably different from one
another – (linear combination of
joint angles)
• Step 2
Values of each discriminant
function are used to construct a
confusion matrix (Information
Theory) that summarizes the
extent to which hand posture
predicts shape.
• Step 3
Entries from the confusion matrix
are further analyzed and a ratio is Raghavan, Santello, Gordon & Krakauer 201 0)
computed (VME index)
Wolff, Raghavan & Gordon (In preparation)

16. Reduced discrimination across objects
Wolff, Raghavan & Gordon (In preparation)

17. Hand function in hemiplegic CP
•Sensory impairments
•Impaired movement execution
•Impaired anticipatory control (Eliasson et al. 1992; Gordon
& Duff 1999).
•Improves during development (Eliasson et al. 2006;
Fedrizzi et al. 2003; Holmefur, et al. 2010).

18. Development of hand function
a 13 year perspective
E
C
N
T
550
Jebson Hand function test
1D
9A
6
C
A5
A
N K PS L
A Y
500
450
400
350
seconds
300
250 hemi1
hemi 2
200 hemi 3
hemi4
150 hemi5
diplegia 1
100 diplegia 2
diplegia 3
50 diplegia 5
mean
0 typical dev
6-8 years 19-21 years
Eliasson, Forssberg, Hung, Gordon. (2006) Pediatrics

19. Experimental data
Temporal pattern
6 year 19 year Typical dev, adult
Gripforce
Grip force
Load force
DLF
DGF
Position
1 sec
Time to lift off
finger differences, preload and loading phase
1,4
1,2
1,0
seconds
hemi 1
0,8 hemi 2
hemi 3
hemi 4
0,6 hemi 5
diplegia 1
diplegia 2
0,4 diplegia 3
diplegia 4
diplegia 5
mean
0,2
6-8 years 19-21 years
typical dev
Eliasson et al 2006
Eliasson, Forssberg, Hung, Gordon. (2006) Pediatrics

20. Hand function in hemiplegic CP
•Sensory impairments
•Impaired movement execution
•Impaired anticipatory control (Eliasson et al. 1992; Gordon
& Duff 1999).
•Improves during development (Eliasson et al. 2006;
Fedrizzi et al. 2003; Holmefur, et al. 2010).
•Improves with intensive practice (Gordon & Duff, 1999;
Duff & Gordon 2003).

21. - 400 gm
--- 200 gm
Gordon & Duff (1999a)

22. Digit individuation improves after training
Individuation Index for the CIMT Group
before CIMT
Average Perform ance
after CIMT
1
0.9
0.8
Individuation Index
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
thumb index middle ring little
Digit
Petra & Gordon (In preparation)

23. Thus, impaired hand function is not static

24. Hand function in hemiplegic CP
•Sensory impairments
•Impaired movement execution
•Impaired anticipatory control (Eliasson et al. 1992; Gordon
& Duff 1999).
•Improves during development (Eliasson et al. 2006;
Fedrizzi et al. 2003; Holmefur, et al. 2010).
•Improves with intensive practice (Gordon & Duff, 1999;
Duff & Gordon 2003).
•Both upper extremities affected.

25. The “less-affected” hand is also affected!
(Gordon & Duff 1999b)

26. Hand function in hemiplegic CP
•Sensory impairments
•Impaired movement execution
•Impaired anticipatory control (Eliasson et al. 1992; Gordon
& Duff 1999).
•Improves during development (Eliasson et al. 2006;
Fedrizzi et al. 2003; Holmefur, et al. 2010).
•Improves with intensive practice (Gordon & Duff, 1999;
Duff & Gordon 2003).
•Both upper extremities affected.
•Impaired bimanual coordination.

27. Impaired bimanual control
Drawer
Handle
Switch
Reflective marker
H
u

28. Impaired bimanual control
Islam et al. (2011)

29. Hand function in hemiplegic CP
•Sensory impairments
•Impaired movement execution
•Impaired anticipatory control (Eliasson et al. 1992; Gordon
& Duff 1999).
•Improves during development (Eliasson et al. 2006;
Fedrizzi et al. 2003; Holmefur, et al. 2010).
•Improves with intensive practice (Gordon & Duff, 1999;
Duff & Gordon 2003).
•Both upper extremities affected.
•Impaired bimanual coordination.
•Role of less-affected hand in rehabilitation?

30. Proprioceptive and tactile information can be
transferred between hands!
(Gordon, Charles & Steenbergen 2006)

31. Simultaneous grasping with both hands may improve grasp
force control in more affected hand,
but potentially at the cost of time.
Steenbergen, Charles & Gordon (2008)

32. Motor Learning
• Motor learning is “a set of processes involving practice and
exercise leading to a relatively stable change in motor
behaviour” (Schmidt 1988)
• Skill is "the ability to consistently attain a goal with some
economy of effort" (Gentile 1987).
• Skill is achievement of the goal rather than the movement
form.

33. Ann Gentile

34. What do we know about motor
learning in CP?

35. What do we know about motor
Conclusions
learning in CP
• We know relatively little
• Performance improves with practice (e.g., Neilson
et al. 1990, Valvano & Newell 1998, Gordon &
Duff 1999, Shumway-Cook et al. 2003)
• Need more practice than TDC

36. What do we know about motor
learning in CP
• We know relatively little
• Performance improves with practice (e.g.,
Neilson et al. 1990, Valvano & Newell
1998, Gordon & Duff 1999)
• Need more practice than TDC.
• Blocked vs. random may not matter (Duff
& Gordon 2003)

37. What do we know about motor
learning in CP
• We know relatively little
• Performance improves with practice (e.g., Neilson
et al. 1990, Valvano & Newell 1998, Gordon &
Duff 1999)
• Need more practice than TDC.
• Blocked vs. random
• Unlike adults, TDC may benefit from feedback,
slower withdrawal, esp. for difficult tasks,
(Sullivan et al. 2008, Goh et al. 2012, Sidaway et
al. 2012, cf. Hemayattalab and Rostami 2009).

38. What do we know about motor
learning in CP
• We know relatively little
• Performance improves with practice (e.g.,
Neilson et al. 1990, Valvano & Newell
1998, Gordon & Duff 1999)
• Need more practice than TDC.
• Blocked vs. random
• Feedback frequency
• Task versus movement

39. Movement quality is higher when
practiced in the context of activities
van der Weel et al. (1991)

40. What do we know …
• Robotic assistive technology: only a select set of
movements needed to promote generalization.” (Krebs et
al. 2012)
• Control strategy is not based on robust knowledge of the
dynamical features of their upper limb (Masia et al. 2011)
• Attentional/executive impairments (Bottcher et al 2009)
• Sequence learning impairments (Gagliardi et al. 2011)
• Learning styles may be important (Smits et al 2011)
• Some children may benefit from teaching cognitive
strategies (Thorpe & Valvano 2002)
• Most of what we know is from laboratory tasks

41. Conclusions
 Motorsystem physiology is highly variable among individuals
with CP, but the impairment patterns (movement execution,
planning and learning) are remarkably consistent.
 Connect clinical and basic research.
 Understanding mechanisms of impairment and recovery
essential to drive the field.

42. Acknowledgements
Clinical studies: Marina Brandao, OT, PhD, Ya-Ching Hung, PT, EdD, Cherie Kuo, PT, Claudio Ferre, MS, Ashley
Chinnan, PT, Jeanne Charles, PT, MSW, PhD, Bert Steenbergen, Eugene Rameckers, PT, PhD, Yannick Bleyenheuft, PT,
PhD
TMS/Imaging: Kathleen Friel, PhD, Sarah Lisanby, M.D., Jason Carmel, M.D. Arielle Stanford, M.D., Stefan Rowny,
M.D., Joshua Berman, M.D. Charles Schroeder, Ph.D., Bruce Bassi, David Murphy, Jaimie Gowatsky, Joy Hirsch, Ph.D.,
Stephen Dashnaw, Glenn Castillo
Volunteers
Participants Supported by:
http://www.facebook.com/CenterCPResearch
Thrasher Research Fund
CVS Caremark
E-mail: ag275@columbia.edu

43. MOTOR LEARNING BASED
TREATMENT
APPROACHES FOR UPPER
EXTREMITY
REHABILITATION IN
CHILDREN WITH
HEMIPLEGIA
Andrew M. Gordon, Ph.D.

44. Overview
• Motor learning in CP
• Motor learning approach to physical
rehabilitation
• Intensity of training
• Specificity of training
• How to achieve intensity
• Skill training and plasticity
• Where to from here?

45. Motor learning based approaches
to rehabilitation
• Janet Carr and Roberta Shepherd
• Rehabilitation involves motor learning
• Pediatric therapists are increasingly aware of
infants and children as active participants rather
than as passive recipients of therapy.

47. Ann Gentile
• “Don’t mislead them by telling them a form that
you think will work.”
• “Establish the goal, set up the regulatory stimulus
conditions…”
• “The behaviour that dominates our daily lives is
directed toward the accomplishment of goals. It is
aimed at a specific purpose or end that we are
trying to achieve”(Gentile 2000, p112).
• Problem solving!!!

48. Pediatr Phys Ther 2001;13:68–76

49. CIMT studies
in CP
Reviews
• More than 70 studies of peds CIMT, 26 RCT
Reviews:
• Sakzewski et al. (2009) Pediatrics. 123(6):e1111-22.
• Gordon (2011) Dev Med Child Neurol.
• Gordon, AM Constraint-induced therapy and bimanual training in children with
unilateral cerebral palsy. In: R Shepherd (Ed.) Cerebral Palsy in Infancy and Early
Childhood Optimizing Growth, Development and Motor Performance. Elsevier. (In
Press).

50. Dosing
Data plotted from Charles et al. 2006; Gordon et al.
2006; Gordon et al. 2007; Gordon et al. 2011
90 hrs CIMT (n=21)
60 hrs CIMT (n=31)
500
Jebsen-Taylor (s)
450
400
350
300
250
200
150
100
Pre-test Post-test
Gordon 2011) DMCN

51. Intensity of practice matters
So CIMT is not a one-time miracle.
F irs t Tx
450
Se c o n d Tx
400
T im e ( s )
350
300
250
F irs t p re te s t F irs t Tx O ne ye a r Se c o n d Tx
Po s t- te s t Po s t- te s t Po s t- te s t
Charles and Gordon (2007) DMCN

52. Motor System Neurophysiology in Children
with Hemiplegic CP
 Ipsilateralconnectivity of impaired hand
may be maladaptive, that children with
this organization pattern have more
severe deficits and are less responsive to
therapies (Kuhnke et al. 2008).
Kuhnke et al.( 2008)

53. International consensus meeting on pediatric CIMT,
January 2012, Stockholm, Sweden

54. And the consensus on what we know
was……
• It works!
• It works in young and older children
• It works when given 24/7 or just 2 hrs/day
• It works with casts, slings, gloves, and no restraint whatsoever
• Repeated bouts work
• A lot of something is better than little or nothing of something else.
• No evidence that any specific model of CIMT demonstrates greater
improvement than another.
• No new knowledge being generated as the same thing tends to be
done over and over across studies.

55. Hand-Arm Bimanual Intensive
Therapy (HABIT)

56. •
HABIT
No restraint
• Same duration as CIMT
• Bimanual activities (e.g., cards,
wrapping presents, video games, ball
throwing, zipping a jacket)
Task Designation
• Stabilizer
• Passive/active assist
• Manipulator
• Gordon et al. (2007, 2008, 2011)
Charles and Gordon, (2006) Dev Med Child
Neurol Nov;48(11):931-6.

57. HABIT Results
Assistin g Hand Asses sment TX Involved
TX Control Involved
Controls 100 Acc elerometry TX Non-Involved
3 Control Non-Involved
95
2.5 90
85
2
80
1.5 75
g
o
L
s
t
i
70
1
65
0.5
60
%
F
a
h
d
o
n
u
q
e
s
v
y
c
)
(
r
f
l
i
55
0
50
Pret es t Imm ediate One m onth
P retest Immedia te One month
post -test po st-test post-tes t post-tes t
Gordon et al. Dev Med Child Neurol. 2008)

58. Dosing
Data plotted from Gordon et al. 2007; Gordon et al. 2011
1.8
1.6 90 hrs HABIT(n=21)
60 hrs HABIT(n=10)
AHA Score (logits)
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Pre-test Immediate 1 month 6 month
Post-test Post-test Post-test
Gordon (2011) DMCN

59. Specificity of practice
Best learning is hypothesized to occur when
practice characteristics are the same as those
of the test (Thorndike 1914, Shea & Wright
1995)

60. Randomized trial comparing CIMT and
bimanual training (HABIT) that
maintains the intensity of practice
associated with CIMT
Hypothesis: participants in the CIMT group will
have greater improvements in unimanual dexterity
whereas participants in the bimanual training group
will have greater improvements in bimanual hand
use—i.e., specificity of training.

61. No specificity of training
HABIT
CIMT
Gordon et al. (2011), Neurorehab & Neural Repair)

62. Effects on Structural Integrity of Motor System on
recovery
R2=.70

63. • Hypothesis: participants in the CIMT group will
have greater improvements in unimanual dexterity
whereas participants in the bimanual training
group will have greater improvements in bimanual
hand use—i.e., specificity of training.

64. Specificity of training
Brandao, Gordon & Mancini, AJOT (2012)

65. Specificity of training
Movement overlap of the two Drawer
Handle
hands increases after
Switch
bimanual training
Reflective marker
Normalized Movement Overlap
0.7
60
Proportion of overlap
0.6
50
0.5 involved HABIT
40
0.4 non-invovled HABIT
30
0.3 Involved CIT
20 non-invovled CIT
0.2
10
0.1
00
pre post
Hung et al. (2011)

66. Specificity of training
Trunk contribution to
unimanual reaching decreases
after CIMT
Displacement (cm)
Treatments
Hung et al. (In Preparation)

67. Combined CIMT/Bimanual training
(AHA)
Pre-test Post-test 8 wks
Aarts et al. 2010

68. Combined CIMT/Bimanual training
Cohen-Holzer et al. 2011

69. Individual or combined
CIMT & HABIT
400
HB 6hs(n1)
AIT0r =0
350
300
250
C T0r (=0
IM hsn2)
6
200
Mid
C3THB(=)id
IM0r Hb
/AIT yr
0 hsn4
/
3
150
m
T
o
a
n
b
e
y
s
J
)
(
r
-
t
i
l
100
Pre te st Im m e d a
i t e 1 m o nt h 6 m o nt h
p o s t te s t p o st te s t p o st te s t
Gordon (2011) DMCN

70. Magic HABIT
Green, Shertz, Gordon, Moore, Schejter Margalit, Farquharson, Ben Bashat, Weinstein, Lin, Fattal-Valevski
(Submitted)

71. Summary
•Both CIMT and bimanual training improve
unimanual and bimanual function similarly in
children with hemiplegia (see also recent studies by
Sakzewski, Wallen, Facchin, Hoare and forthcoming studies by
Deppe).
•Bimanual training may improve coordination of
the two hands to a greater extent and allow practice
of functionally meaningful goals, whereas
unimanual training may improve unimanual control.
•Not mutually exclusive of each other, and can
perhaps be combined over time as seen fit.

72. Hand-Arm Bilateral Intensive Therapy Involving Lower
Extremities (HABITILE)
• Examined the efficacy of a novel
intensive intervention including
systematically training upper
and lower extremities (LE) in
children with hemiplegic CP
• 12 children 6-13 years of age in
sleep-over camp in Brussels
• 90 hours training
• LE training included seating
children on fitness balls or
having them stand on balance
boards during manual activities,
gross motor activities, strength
training, and use of a climbing
wall
Bleyenheuft et al. (In Preparation)

73. HABITILE: Results
100
90
80
AHA (% of logits)
70
60
6
ABILHAND-Kids (logits)
50
4 40
P<0.001
30
2 T0 T1 T2 T3
Pre-tests Post-test
0
P<0.001 650
-2
P=0.005
6 minutes walking test (m)
T0 T1 T2 T3 600
550
Pre-tests Post-tests 500
450
400
350
Bleyenheuft et al. (In Preparation) 300
T0 T1 T2 T3

74. Simona Bar-Haim et al (2010) Effectiveness of
motor learning coaching in children with cerebral
palsy: a randomized controlled trial. Clin Rehab 24:
1009-1020
• Evaluated effectiveness of motor learning on
retention and transfer of gross motor function in
children with CP.
• 78 children with spastic cerebral palsy, gross
motor functional levels II and III, aged 66 to 146
months.
• 1 hr/day, 3 days/week for 3 months treatment with
motor learning coaching or neurodevelopmental
treatment:

75. Improvements in GMFM-66 retained
after motor learning coaching
NDT
MLC
Pretest Post-test 3 mos 9 mos
Plotted from, Bar-Haim et al. 2010

76. Does it matter who provides
training and where?

77. Preschoolusual and customary
Rethink environment--No
specificity of schedule?
care school training
Gelkop, D. Goal, Lahav, Brezner, Oribi, Ferre, Gordon ( In Preparation)

78. Does it matter whether PTs/OTs provide the
training?
JTTHF Change Score by Interventionist AHA Change Score by Interventionist
Type Type
200 8
180 7
160
6
140
AHA Logit Scale
5
120 PT/OT PT/OT
Seconds
100 Non-PT/OT 4 Non-PT/OT
80 3
60
2
40
1
20
0 0
Plotted from Gordon et al. 2011

79. Home CIMT by therapists
Al-Oraibi & Eliasson et al. 2011

80. Feasibility of a Home-based Hand-arm Bimanual Intensive
Training for Young Children with Hemiplegic Cerebral Palsy
Ferre et al. In Preparation
Poster session 2, #156

81. Children with hemiplegic
CP (n=7) age 1.5 to 4 years
9 weeks
Caregivers administer HABIT under supervision of a
trained interventionist 2hrs/day, 5x/week
Ferre et al. In Preparation

82. Preliminary Results: Bimanual hand use
Ferre et al. In Preparation

83. Summary
•Benefits of intensive motor learning based
therapies not limited to upper extremities.
•CIMT/Bimanual therapy can be administered in
camps, schools and home by therapists, trained
students or caregivers.

84. Skill training
• Newly learned movements are represented over
large cortical areas (e.g., Kleim et al. 1998, Plautz
et al. 2000)
• "repetitive motor activity alone does not produce
functional reorganization of cortical motor
maps… Instead, motor skill acquisition, or motor
learning, is a prerequisite factor in driving
representational plasticity in motor cortex” (Nudo
2003).

85. Feline model of forced use and skill
training
• Restrain unaffected forelimb (jacket with
one sleeve tethered to chest), forced use of
affected limb
– 23 hrs per day
– Either restraint alone or paired with daily reach
training (1 hr per day)
• Restraint +/- training from 8-13 weeks of
age, “early training”, immediately following
the period of M1 inactivation
Friel Ket al. Neurosci. 2012; 32: 9265-76.

86. Early training improves ladder
stepping accuracy to normal levels
Friel K, Chakrabarty S, Kuo HC, Martin J. J Neurosci.
2012; 32: 9265-76.

87. Early Training Results in Upregulaltion
of Choline Acetyltransferrase (ChAT)
 Incat model, hemiplegia without rehabilitation decreases
cholinergic function in spinal cord interneurons (Chakrabarty et
al. 2009).
 Early training - large amounts of ChAT on affected side.
 No increases in ChAT on the affected side, compared to the
unaffected side, after restraint alone.
Friel K, Chakrabarty S, Kuo HC,
Martin J. J Neurosci. 2012; 32: 9265-
76.

88. Does structured practice matter?
• RCT of 24 children, age 6-14yrs
• Structured practice group: Environmental
constraints manipulated, skill progression, part-
practice (shaping), goal-directed.
• Unstructured practice group: Bimanual play
• Day-camp environment, 6 hrs/day, 15 days
• AHA, Jebsen-Taylor, Abilhand-Kids, COPM
• Testing immediately before and after tx, 6-
months
• Evaluator and interventionists blinded et al. In Preparation
Brandao

89. Hypothesis: participants in the structured skill
practice group will have greater
improvements than participants unstructured
practice group

90. Similar improvements regardless
of practice type
Brandao et al. In Preparation

91. Hypothesis: participants in the structured skill
practice group will have greater
improvements than participants unstructured
practice group

92. Cortical representations
• Single-pulse TMS mapping, Magstim
200 stimulator, figure-8 coil.
• Co-registered TMS stimulation sites to
individual MRIs, Brainsight software.
• Recorded EMG in digit, wrist, and
biceps muscles bilaterally during TMS.
• Mapped hand representation bilaterally,
1 cm intervals, centered around spot of
greatest activation of digit muscle.
• Mapping intensity – 110% pre-training
motor threshold.
• Same TMS intensity used before and
after training.
Friel et al. In Preparation

93. Intensive bimanual training improves hand function
irrespective of CST pattern
N=4
N=7
N=2
** **

94. TMS Map – Affected Hand,
Structured Skill Training

95. Expansion and Strengthening of
Ipsilateral Map of Impaired Digit

96. • Hand Map expands for structured practice group
• But not for unstructured practice group
• Motor Learning!!!
Friel et al. In
Preparation

97. Summary
• At least at such high training dosage,
structured skill progression may not matter.
• Skill training is optimal for improvement in
functional goals and motor cortical plasticity.
• There may be a dichotomy between plasticity
measured using tms and behavior—what does
“M1 plasticity” mean?

98. Conclusions
• How do you get to Carnegie Hall?
• If you want to play the violin…
• Intensity matters!
• But “intensity is necessary but not sufficient”
(Schertz & Gordon 2008)
• Who, what, where?
• We are working with individuals
• Go beyond clinical outcome measures
• The key may be goal-oriented training
involving motor learning

99. Don’t be satisfied—we need to
know so much more to optimize
rehabilitation
Neural
Development and
Systems mechanisms
neuroscience, testing of rehabilitation
underlying
motor learning & protocols
movement
control
disorders