JOHN P. SCHOLZ, PT, PHD
PROFESSOR, DEPARTMENT OF PHYSICAL THERAPY,
UNIVERSITY OF DELAWARE
A brain attack or stroke can have a devastating effect on the patient as well as his/her family. Movement and, sometimes, cognitive functions that were once performed automatically now require great effort and new strategies, if they can be performed at all. The patient’s family is often torn between sympathy combined with the compulsion to do as much as possible for the patient and anger at the additional burden this tragedy brings to their own lives.
In the early stages following a stroke, the patient is often bewildered by the sudden loss of even the most basic functions. As initial recovery progresses, he/she becomes understandably torn between the expectation that full recovery is only a matter of time and the frequent reality that some functional deficit is likely inevitable. What can the patient expect from rehabilitation?
Immediately after the stroke, the focus of the medical staff is to medically stabilize the patient. At this stage, physical therapy (PT) consists largely of attempts to prevent the loss of joint motion that can occur due to tightening of muscles and ligaments that are not moved through their full available range. Early exercise also helps to minimize the loss of muscle strength that occurs with disuse of the limb. As soon as the patient’s medical condition has stabilized, however, aggressive therapy becomes an essential ingredient to promote the patient’s long-term recovery.
Because of time limitations resulting from the rising cost of health care, initial rehabilitation often emphasizes teaching the patient to compensate for the loss of control of the extremities on the side affected by the stroke. Although recovery of function is of greatest importance following a stroke, it is important for clinicians not to be short sighted about the long-term implications’ of neglecting the patient’s most affected side. Failure to help the patient develop strategies that actively and appropriately incorporate the affected extremities into daily tasks often leads to a greater risk of falls and other accidents because the patient has no practice in controlling the impaired side of the body. Moreover, an aspect of rehabilitation that is often neglected is control of the trunk. The trunk is essential for postural stability in sitting and standing, serves as a base of support from which the arms and legs are able to work, and allows extension of the functional use of our extremities when objects are beyond our typical reach length. Thus, coordinated function of the trunk with the extremities is an essential aspect of rehabilitation that should not be neglected.
Although a course of inpatient rehabilitation is typically shorter today than in the past, most patients receive some form or continued therapy after discharge, either as an outpatient or with the guidance of a home health therapist. This additional therapy provides an important opportunity to address control issues of the trunk and the extremities affected by the stroke. Unfortunately, an important window of opportunity may have already closed by this time if early rehabilitation focused solely on learning compensations for the affected extremities. Thus, early treatment aimed at getting the patient functional enough for discharge must be tempered by an understanding of the need to foster use of the most affected side of the body as much as possible.
Guidelines for improving motor skill:
Several implications for rehabilitation come from recent studies of the brain’s ability to recover function after a lesion. Some important lessons follow:
- Begin practice as soon as possible following a stroke (i.e., once the patient is stable medically).
- Treatment should emphasize the practice of functional skills that incorporate use of affected extremities as much as possible.
- Treatment should challenge the patient’s abilities, within appropriate limits of other medical conditions/ contraindications and the need to ensure safety.
- Treatment should vary as many aspects of a task’s practice as possible (e.g., the size, shape, texture and weight of objects being manipulated) and should allow the patient opportunities to self-evaluate their performance so that they do not become dependent on outside assessment.
- Feedback is important for learning. Providing external feedback too frequently, however, can be detrimental to learning.
- Extensive practice is essential for recovery of function. The amount of practice available in most therapy sessions is not adequate to maximize functional recovery. Patients must engage in frequent and quality practice of skills outside of formal therapy if recovery is going to be optimal.
Newer Therapies for Stroke Rehabilitation:
In recent years, a number of therapeutic approaches have been introduced to help re-train movement function in persons following a stroke. Examples of more commonly used clinical approaches to rehabilitation include Constraint-Induced Movement Training (CIMT) and Body-weight supported treadmill training (BWSTT). CIMT, in particular, is based on point #6 above. Participants agree to keep their non-impaired upper extremity in a splint while intensively practicing functional tasks with their impaired extremity. Treatment is both intense and short-term, typically lasting 6-hours per day for about two weeks, although modified versions have been recently implemented in some clinics. CIMT was developed to improve arm function, although a variant of the approach also has been applied to train walking post-stroke.
BWSTT attempts to improve a patient’s confidence in bearing weight on the affected leg by providing partial body weight support while the patient walks on a treadmill. The support is maximal at first and then gradually decreased to no additional support over a number of treatment sessions. In addition, it is useful to increase the treadmill speed to help the patient gain confidence walking at faster speeds.
More recent experimental innovations introduced in recent years include Robotic Assisted Training (RAT), either applied to improve arm function or walking ability, Split-Belt Treadmill Training (SBTT) and Fast-FES Treadmill Training (FFTT) for walking. FFTT involves practice of walking at higher than normal speeds while functional electrical stimulation (FES) is applied to the ankle muscles to assist their contraction. SBTT attempts to help the subject learn to bear weight for equal time periods on both the impaired and non-impaired legs. RAT uses computer-controlled robots to assist or resist movement of the arm or leg while patients attempt to perform functional tasks. None of these approaches are in standard use clinically but have potential to improve function in persons post-stroke. Most insurance companies do not pay for these latter treatments because they are still considered experimental. However, variants of all three are currently under study at the University of Delaware Department of Physical Therapy and volunteers are currently being enrolled for trial therapy with them.
Some treatments like CIMT have been shown to be effective only in individuals with mild impairment of their hand function. Patients with more significant impairments of their arm and hand would not qualify for this therapeutic approach at the present time. Thus, while these and a number of related treatments not mentioned here provide hope for the stroke survivor, it is still too early to know how widely useful they will be.
Local Rehabilitation Studies:
As mentioned above, the Department of Physical Therapy at the University of Delaware is engaged in a number of ongoing research projects aimed at better understanding functional loses after a stroke and to develop improved treatment methods. For further information on how you can become involved in this research, please contact Ruby, our research scheduling coordinator, at (302) 831-0150 or UDPTResearch@udel.edu.