Comparing distributed versus massed practice on functional recovery and Brain-Derived Neurotrophic Factor (BDNF) in acute stroke subjects

INTRODUCTION

Stroke is the second most common cause of mortality in the world and is a serious health issue on a global scale.^[1] The mainstay of the treatment for stroke survivors to recover from lingering motor deficits is a rehabilitation program.^[2]

Improved arm-hand functions, gait and mobility, and activities of daily living (ADL) activities are the results of novel rehabilitation strategies involving diverse physiotherapy treatment modalities such as early mobilization, balance training, task-oriented training, and gait training.^[3,4] The accelerated skill acquisition program (ASAP), an evidence-based intervention, was created with modern motor learning concepts to address post-stroke deficits.^[5,6] Brain-derived neurotrophic factor (BDNF), which is known to prevent neuronal cell deaths during cerebral ischemia and to further improve synaptic and axonal plasticity associated with learning, memory, and sensori-motor recovery, is a crucial component in controlling neuroplastic changes in the brain.^[7] The physical activity raised BDNF concentrations in studies using animal stroke models, according to Alcantara et al.’s review, which also called for greater research on human BDNF responses to exercise training.^[8]

Neuro-rehabilitation following a stroke is a process of re-learning and skill acquisition.^[9] Practice is a crucial part of motor learning, and its variables – such as quantity, variety, and schedule – ensure that movement quality, function, and timing improve in line with increased movement capabilities.^[9] In distributed practice, the exercises are interspersed with longer rest intervals than the entire duration of exercises, whereas in massed practice, all exercises must be performed, which limits the rest within the sessions.^[10] Massed and distributed scheduling of practice demonstrates benefits in several types of skills, including continuous and discrete tasks, respectively.^[11]

The diversity of practice in acute stroke rehabilitation was less well-studied because it is the most important part of motor learning. Studies on the impact of mobility training and practice schedules on motor and functional recovery during early stroke rehabilitation are lacking. To examine the effects of massed versus distributed practice on functional recovery and BDNF in acute stroke rehabilitation, this study was conducted.

MATERIALS AND METHODS

Non-randomization and blinding

The research was set up in a parallel group. The study was set up as a non-randomized experiment in a parallel group. A.N., a member of the research team who was blind to the assessment and intervention, randomly assigned 16 volunteers to each of the two intervention groups (massed practice group and distributed practice group) for our study, which enrolled 32 acute stroke patients. A.N., who was in charge of allocating funds, was not engaged in the selection of participants, their evaluation, or the delivery of intervention programs. The assessment and intervention plans for the participants were organized by V.K. and M.K. A description of the process is provided in Figure 1.

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Figure 1:

Participant flowchart. MMSE: Mini-mental state examination.

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RESULTS

The demographic baseline information for the various categories is shown in Table 1. Along with their p values, the median values for age, post-stroke time, BRS (UE, hand, and LE), MRS, and MMSE scores for both grouped and scattered individuals are provided. These findings imply that there are no appreciable changes between a MG and DG in terms of age, post-stroke duration, BRS (UE, hand, and LE), MRS, or MMSE scores. With p values of 0.252, 0.167, 0.704, and 0.767, respectively, the other demographic characteristics, such as gender, risk factors, stroke type, and side of hemiparesis, are equally distributed between the two groups.

The raw median of STREAM (UE, LE, and basic mobility), MBI, and BDNF for participants in both groups (massed and distributed) before and after intervention is shown in Table 2. Both massed and distributed practice groups showed post-intervention improvements in all three outcome measures (STREAM, MBI, and BDNF) with P = 0.05; however, the distributed practice group showed more pronounced changes than the massed practice group. When the groups' modified median STREAM (UE, LE, and basic mobility), MBI, and BDNF scores were compared, no statistically significant differences were seen with P > 0.05.

DISCUSSION

According to the findings of our study, both practice schedule groups (massed and distributed) demonstrated a discernible improvement across all outcome metrics. Animal studies have accumulated a growing body of evidence that suggests early exercise training (<72 h after a stroke) encourages neuroplastic changes, has positive effects on biomarkers, and improves functional recovery from stroke.^[17,18] Few studies have focused on the importance of beginning an exercise-based physical rehabilitation intervention within the first 2 weeks following a stroke.^[3,19] The key finding of the current study is that ASAP-based therapies improved learning due to neuroplastic changes, early physical therapy intervention in the window period, and may benefit very early stroke rehabilitation.

The key components of stroke therapy are recognized to be providing motor training at the right time and in the right amount.^[20] All of the individuals in our study had active therapy for 45–60 min each day. As per the National Institute for Health and Care Excellence’s established guidelines for stroke rehabilitation, this might have aided the functional improvements of our participants.^[21]

Motor learning, which is related to long-term changes in a patient’s capacity to perform a motor function after a stroke, leads to motor recovery.^[22] Our ASAP-based therapy sessions included active participation, a problem-solving strategy that boosted their motivation and involved them in active participation to facilitate motivation, self-reliance, and self-determination, which may have sped up the learning process to improve stroke recovery.^[23]

Enhanced STREAM scores, which are connected to motor learning, show that the repeated practice of the exercise prescribed by the therapist would have enhanced the quality of movement at the conclusion of therapy sessions.^[24] The exercises given to the participants involved vigorous movement of the extremities in the controlled setting of the hospital, which offered the best learning environment.^[10]

The massed practice group, which included stroke participants, engaged in the practice of physical activities in continuous and repeated training in a blocked way without clear start and stop points, which may have improved motor performances.^[25] With greater BRSs and higher cognitive functioning (as measured by MMSE scores), the participants in this group may have recovered more quickly and effectively.

The distributed practice incorporates interval training for the person. According to this study, individuals in this group recovered more quickly than those in the mass practice group, showing that the spacing between activities in this group increased recovery rates and decreased participant’s fatigue.^[26] Spacing decreased the training’s cognitive demand, resulting in greater post-rehabilitation recovery.^[27] According to studies, spacing improves recollection of the task, the learning process, and ultimately results in greater motor skill performance.^[28,29]

This follows a study by Partibhan et al. that demonstrated enhanced performance in a dispersed group where participant spacing reduced the cognitive strain.^[30] Both practice groups’ BDNF levels increased post-intervention, although there were significant variations between massed practice and scattered practice. There is some weak evidence that suggests exercise training causes BDNF to be upregulated, which primes the brain to improve motor learning.^[31] This rise in BDNF levels in our study may have aided participant performance and the learning process, resulting in improved motor function. In contrast to earlier research that used aerobic exercise and activity-dependent training, our study used ASAP rehabilitation and found that blood BDNF levels increased in sub-acute and chronic individuals.^[32]

The intensity and frequency of exercises within sessions were raised during massed practice, which entailed continuous training without rest periods. In contrast, during distributed practice, the break periods caused the intensity of exercises within sessions to decrease. This can be related to the fact that BDNF values change significantly more during massed practice than during distributed practice because exercise conditions (such as type and intensity) control these changes.^[33]

CONCLUSION

This study focused on the skill-based training program in acute stroke rehabilitation by manipulating the practice sessions under the effect of ASAP’s core concepts. To the best of our knowledge, this study offers the first supporting data for early stroke rehabilitation using an ASAP-based intervention. In very early stroke therapy, distributed practice can be used to improve motor and functional recovery while also lowering cognitive and mental fatigue.