Presented by: Shawn Baker, PT, DPT
Leslie Brady, PT, MPT
Baylor Institute for Rehabilitation

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Discuss 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.

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Neuro: Nerves and/or brain
Plasticity: Moldable or changeable in structure
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Speaks to the adaptive capacity of the central nervous system
Brain is not a static organ
Brain changes throughout life and after injury

 LEARNING 1
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Best hope for remodeling the damaged brain
Reorganizes the damaged brain, even in the absence of rehabilitation
Brain damage changes the way the brain responds

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Treatment Approaches used in the Inpatient Rehabilitation Setting

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Body weight support treadmill training
Constraint induced therapy
Functional electrical stimulation
Mirror therapy
Use of tape

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Characteristics of gait after stroke
BWSTT provides environment to relearn normative gait
Parameters to consider include:
 Amount of weight supported
 Speed
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UE support
Use of brace
Findings

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Forced use of the affected extremity
Limiting use of non-affected extremity with constraining device
Parameters to consider include:
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Amount of day constrained
Type of constraining device
 Behavior contracts
Findings

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Electrical stimulation over affected muscle groups
Combined with practice/activity
Parameters to consider:
 Amount of stimulation
 Which activity
 Contraindications/precautions
Findings

5,6
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Mirror placed in midsagittal plane
Reflecting movements of non-affected side as it were the affected side
Parameters to consider include:
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Amount of time per day
Use of mirror box or upright mirror
Findings

 Uses for tape in rehabilitation setting:
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Shoulder subluxation
Knee hyperextention
Edema
 Types of tape used:
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Kinesiology tape
Corrective tape
 Findings

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CMS requirements and Three hour rule
Cognition
Communication
Dysphagia/pneumonia
Bowel/bladder incontinence
Pain
The “pusher”

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Based on assessment
Criteria must be met at time of admission:
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Require active and ongoing intervention of multiple disciplines
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Reasonably be expected to actively participate and benefit from therapy program
Requires physician supervision
Requires intensive and coordinated interdisciplinary team approach

7
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3 hours of therapy per day, at least 5 days per week
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Acceptable cancel reasons
Make up time if necessary
PT, OT, ST only count
In certain cases, 15 hours over a 7 consecutive day period
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Must be well-documented
Order by physician

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How much is needed to cause impairment?
 Greater than 10mL but less than 50mL which equals 1-4% of brain volume 8
Vascular Cognitive Impairment (VCI)
 Affects in executive function 9
Cognitive deficits include:
 Attention, language syntax, delayed recall and executive dysfunction affecting the ability to analyze, interpret, plan, organize, and execute complex information 9
Multicenter study found 56% of patients report confusion after CVA 10

 Safety 10
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Pressure sore/skin break 21%
Fall, serious injury 5%
Fall, total 25%
 Causes of falls in community dwelling stroke survivors 11
 Difficulty stooping and kneeling
 Getting up in night to urinate more than once

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What is language?
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Recognize and use words and sentences
Much of the capability resides in left hemisphere
Aphasia 12-14
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1 million people in the US have aphasia
Ability to use or comprehend words
Apraxia 12-14
 Difficulty initiating and executing voluntary movement patterns necessary to produce speech when there is no paralysis or weakness of speech muscles
Dysarthria 14-15
 Motor speech disorder

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Swallowing process disrupted
65% of stroke survivors experience dysphagia 16
Aspiration can occur
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Aspiration pneumonia 17
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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

18,19
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Affects 40-60% of patients admitted to hospital after CVA
15% have ongoing problems one year after CVA
 Can affect:
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Equipment ordered for home use
Discharge placement
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Incontinence associated with poorer functional outcomes
Increased institutionalization

20
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Musculoskeletal
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Spasticity
Shoulder/hand pain
Central Pain
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Constant, moderate to severe pain
Brain registers even slight contact to skin as painful
Reported in approximately 8%
 Onset more than a month after stroke

21,22
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Distinctive disorder of actively pushing away from nonhemiparetic side
Present in approximately 10.4% of patients
Patient’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

Thank you!

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Rehabilitation After Brain Damage. Journal of Speech, Language, and Hearing Research. Vol 51
2. McCain, K.J., et al. (2008). LocomotorTreadmill 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

8. 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/RegainingIndependenc e/CommunicationChallenges/Conditions-Impacting-Communication-After-
Stroke_UCM_310071_Article.jsp
13. Aphasia vs Apraxia. Retrieved from: http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependenc e/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

15. Dysarthria. Retrieved from: http://www.asha.org/public/speech/disorders/dysarthria/
16. Difficulty Swallowing After Stroke. Retrieved from: http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndepende nce/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