Presented by: Shawn Baker, PT, DPTLeslie Brady, PT, MPT
Baylor Institute for Rehabilitation
Rehabilitation of the Stroke Patient
ObjectivesDiscuss basic principles of neuroplasiticity
after injury.Review treatment approaches used in the
inpatient rehabilitation setting with regards to the stroke population.
Discuss challenges with the stroke patient in the rehabilitation setting.
What is Neuroplasticity?Neuro: Nerves and/or brainPlasticity: Moldable or changeable in
structure
Speaks to the adaptive capacity of the central nervous system
Brain is not a static organBrain changes throughout life and after
injury
Neuroplasticity After Brain DamageLEARNING1
Best hope for remodeling the damaged brainReorganizes the damaged brain, even in the
absence of rehabilitationBrain damage changes the way the brain
responds
Neuroplasticity After Injury1
Use it or lose itUse it and
improve itSpecificityRepetition
mattersIntensity
matters
Time mattersSalience
mattersAge mattersTransferenceInterference
What Exactly Are Patients Doing in Therapy?
Treatment Approaches used in the Inpatient Rehabilitation Setting
Treatment Approaches Body weight support treadmill trainingConstraint induced therapyFunctional electrical stimulationMirror therapyUse of tape
Body Weight Support Treadmill Training (BWSTT)2
Characteristics of gait after strokeBWSTT provides environment to relearn
normative gaitParameters to consider include:
Amount of weight supportedSpeedUE supportUse of brace
Findings
Videos!
Constraint Induced Therapy3
Forced use of the affected extremityLimiting use of non-affected extremity with
constraining deviceParameters to consider include:
Amount of day constrainedType of constraining deviceBehavior contracts
Findings
Functional Electrical Stimulation4
Electrical stimulation over affected muscle groups
Combined with practice/activityParameters to consider:
Amount of stimulationWhich activity Contraindications/precautions
Findings
Mirror Therapy5,6
Mirror placed in midsagittal planeReflecting movements of non-affected side
as it were the affected sideParameters to consider include:
Amount of time per dayUse of mirror box or upright mirror
Findings
Use of TapeUses for tape in rehabilitation setting:
Shoulder subluxationKnee hyperextentionEdema
Types of tape used:Kinesiology tapeCorrective tape
Findings
Challenges We Face With Stroke Patients
Inpatient Rehabilitation ChallengesCMS requirements and Three hour ruleCognitionCommunicationDysphagia/pneumoniaBowel/bladder incontinencePainThe “pusher”
Determination of IRF Stay7
Based on assessmentCriteria must be met at time of admission:
A. Require active and ongoing intervention of multiple disciplines
B. Require an intensive rehabilitation therapy program
C. Reasonably be expected to actively participate and benefit from therapy program
D. Requires physician supervisionE. Requires intensive and coordinated interdisciplinary
team approach
Intensive Rehabilitation Program7
3 hours of therapy per day, at least 5 days per weekAcceptable cancel reasonsMake up time if necessaryPT, OT, ST only count
In certain cases, 15 hours over a 7 consecutive day periodMust be well-documented Order by physician
CognitionHow much is needed to cause impairment?
Greater than 10mL but less than 50mL which equals 1-4% of brain volume8
Vascular Cognitive Impairment (VCI)Affects in executive function9
Cognitive deficits include:Attention, language syntax, delayed recall and
executive dysfunction affecting the ability to analyze, interpret, plan, organize, and execute complex information9
Multicenter study found 56% of patients report confusion after CVA10
Cognition ContinuedSafety10
Pressure sore/skin break 21%Fall, serious injury 5%Fall, total 25%
Causes of falls in community dwelling stroke survivors11
Difficulty stooping and kneelingGetting up in night to urinate more than once
CommunicationWhat is language?12
Recognize and use words and sentencesMuch of the capability resides in left hemisphere
Aphasia12-14
1 million people in the US have aphasiaAbility to use or comprehend words
Apraxia12-14
Difficulty initiating and executing voluntary movement patterns necessary to produce speech when there is no paralysis or weakness of speech muscles
Dysarthria14-15
Motor speech disorder
DysphagiaSwallowing process disrupted65% of stroke survivors experience dysphagia16
Aspiration can occur
Aspiration pneumonia17
Dysphagia carries threefold to sevenfold increase increased risk
Patient has threefold increased risk of death if developing
Dysphagia is a predictor of mortality after stroke
Bowel/Bladder Incontinence18,19
Affects 40-60% of patients admitted to hospital after CVA
15% have ongoing problems one year after CVA
Can affect:Equipment ordered for home use Discharge placement
Incontinence associated with poorer functional outcomes
Increased institutionalization
Pain20
MusculoskeletalSpasticityShoulder/hand pain
Central PainConstant, moderate to severe pain Brain registers even slight contact to skin as
painfulReported in approximately 8%Onset more than a month after stroke
Pusher Syndrome21,22
Distinctive disorder of actively pushing away from non-hemiparetic side
Present in approximately 10.4% of patientsPatient’s perceived “upright” orientation was
tilted about 18 degrees toward ipsilesional side with eyes occluded
Patients with pusher syndrome take 3.6 weeks (63%) longer to reach same functional outcome level
Sitting on a tilting chair, patients with pusher syndrome were required to indicate when they reached “upright” body orientation.13 (a) With occluded eyes, the patients experienced their body as oriented
“upright” when actually tilted 18 degrees to the side of the brain lesion.
Karnath H , and Broetz D PHYS THER 2003;83:1119-1125
Physical Therapy
Questions?
Thank you!
References1. Kleim, J.A. (2008). Principles of Experience-Dependent Neural
Plasticity: Implications for Rehabilitation After Brain Damage. Journal of Speech, Language, and Hearing Research. Vol 51
2. McCain, K.J., et al. (2008). Locomotor Treadmill Training with Partial Body-Weight Support Before Overground Gait in Adults with Acute Stroke: A Pilot Study. Archives of Physical Medicine and Rehabilitation. Vol 89
3. Wolf, S. et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke. Journal of the American Medical Association. 2006; 296:2095-2103
4. Yan, T., et al. (2005). Functional Electrical Stimulation Improves Motor Recovery of the Lower Extremity and Walking Ability of Stroke Subjects With First Acute Stroke: A Randomized Placebo-Controlled Trial. Stroke. 2005;36:80-85.
5. Sutbeyaz, S., et al. (2007). Mirror Therapy Enhances Lower-Extremity Motor Recovery and Motor Functioning After Stroke: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation. Vol 88
6. Thieme H., et al. (2012). Mirror therapy for improving motor function after stroke. Cochrane Database of Systematic Reviews 2012, Issue 3
7. Inpatient Rehabilitation Therapy Services : Complying with Documentation Requirements. Retrieved from: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Inpatient_Rehab_Fact_Sheet_ICN905643.pdf
References Continued8. Stroke and Cognitive Impairment. Retrieved from:
http://www.preventad.com/pdf/support/article/Stroke_Cognitive_Impairment.pdf
9. Stroke: Challenges, Progress, and Promise. Retrieved from: http://stroke.nih.gov/materials/strokechallenges.htm#Basics3
10.P.Langhorne, D.J., et al. (2000). Medical Complications After Stroke: A Multicenter Study. Stroke. 2000;31:1223-1229
11.Mackintosh, S. F., et al. (2005). Falls incidence and factors associated with falling in older, community-dwelling, chronic stroke survivors (>1 year after stroke) and matched controls. Aging Clinical and Experimental Research. Vol 17, Issue 2
12.Conditions Impacting Communication After Stroke. Retrieved from: http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/CommunicationChallenges/Conditions-Impacting-Communication-After-Stroke_UCM_310071_Article.jsp
13.Aphasia vs Apraxia. Retrieved from: http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/CommunicationChallenges/Aphasia-vs-Apraxia_UCM_310079_Article.jsp
14.Speaking of Stroke: Why Speech May be Affected by Stroke. Retrieved from: http://www.nxtbook.com/nxtbooks/aha/strokeconnection_20100506/index.php#/16
References Continued15.Dysarthria. Retrieved from:
http://www.asha.org/public/speech/disorders/dysarthria/16.Difficulty Swallowing After Stroke. Retrieved from:
http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/PhysicalChallenges/Difficulty-Swallowing-After-Stroke_UCM_310084_Article.jsp
17.Singh, S. and Hamdy, S. (2006). Dysphagia in Stroke Patients. Postgraduate Medical Journal. 82(968): 383–391
18.Continence Problems After Stroke. Retrieved from: http://www.bladderandbowelfoundation.org/uploads/pdf/F12_Continence_problems_after_stroke,_March_2011[1].pdf
19. Mehdi, Z., Birns, J. and Bhalla, A. (2013), Post-stroke urinary incontinence. International Journal of Clinical Practice, 67: 1128–1137.
20.Pain. Retrieved from: http://www.stroke.org/site/PageServer?pagename=pain
21. Karnath, H.O., et al. (2007). Pusher Syndrome-a frequent but little-known disturbance of body orientation perception. Journal of Neurology. 254:415-424
22. Karnath, H.O. and Broetz, D. (2003). Understanding and Treating “Pusher Syndrome”. Physical Therapy. Volume 23, Number 12