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