Principles of Neurorehabilitation Applied Post-Stroke

Taylor Cocuzza

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 The first principle, “Use It Or Lose It” focuses on the fundamental concept that if a

patient does not use the affected limb(s) or behaviors, they will eventually develop a learned

non-use for that limb. In result, neural efficacy will decline for those specific brain connections

as well as muscular atrophy, which could potentially lead to difficulty or inability for restoration of

function. The second principle, “Use It and Improve It” holds similar values as “Use it or Lose

It.” It refers to the ability to restore or improve functional deficits caused by the neurological

injury on the basis of activating the specific brain functions that were impacted. Therefore, by

using what was affected, a patient can not only prevent complete loss of function, but improve

functional ability as well. The implementation of these principles is quite straightforward. The

therapist will develop a treatment plan that requires the patient to use the limb(s) affected by

neurological injury. This could also be applied to any other impairment such as dysarthria,

aphasia, ataxia, dysphagia, spatial neglect, etc. Therefore, this patient will be required to use his

right arm and hand, whether actively or passively, during therapy and in everyday application

outside of the clinic and overtime, improve function. Some techniques could be applied which

include the Constraint Induced Movement Therapy (CIMT), which involves restricting the non-

affected limb for extended periods of time. I am able to address these principles by applying

this type of treatment because if a patient is required to progressively use the affected limb, they

increase the usage of that limb and the potential of improving overall function of what was

affected by increasing sensory and motor representations in the cortex. This can also prevent

him from adapting and using his left-hand to complete his everyday routines.

Although using the limb is beneficial, it is important to focus on performing therapy that is

specifically aimed to that patient’s deficits and goals by applying the third principle, “Specificity

Matters.” Similar to muscles, you can’t improve the neural plasticity of a specific brain region

unless you actually engage that particular region. The implementation of this principle would

be directed with the idea that every patient is different and the Plan Of Care should concentrate

on regaining skills that would allow our patient to return to work and perform daily tasks as a

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father and husband. Our patient has moderate difficulty both grasping objects with his right hand

as well as holding his right arm up against gravity. He has mild aphasia and loss of sensation of

the right upper extremity. Being a plumber, it is important to regain overall strength and grip

strength in his dominant hand. Catering to the first two impairments could be implemented by

applying exercises that work to improve strength and range of motion. These strengthening

exercises would require using the right arm to actively or passively, with or without Electrical

Stimulation (ESTIM), to perform exercises that activate muscles within the shoulder girdle and

upper extremity. One would also apply pinch and grip strengthening, upper extremity weight

bearing, and cognitive-speech exercises into treatment. The strengthening and weight-bearing

exercises will address this principle because it will improve functional connectivity for regions

that affect his ability to hold his arm up against gravity as well as gripping objects. Exercise with

a combination of manual therapy, ultrasound, and E-STIM can also improve loss of sensation in

that limb as well. To engage the networks and produce a result within the brain that affect his

aphasia, one could address this and either having him attend speech therapy, or apply this

concept in combination with exercise. With mild aphasia, it is common that the patient has

trouble interpreting complex conversations or determining correct word(s) to use. An example of

implementation could be an exercise where the patient is seated and must reach with one arm

in various planes to grab a clothespin with instruction to pin it overhead to a rim all while weight-

bearing on the other upper extremity; the clothespin will have a letter or color on it or and you

can ask the patient to identify a word that starts with that letter or one that rhymes with that

color. This will address the principle because it requires engaging multiple body parts and

pathways that were impacted by the stroke. The particular exercises and extent of using E-

STIM, passive ROM, particular activities are dependent on the patient’s current capabilities and

the severity of impairment within that moderate range.

The fourth and fifth principles of neuroplasticity—“Duration Matters” and “Repetition

Matters”—tend to go hand-in-hand with treatment. Duration implies that gains in neural plasticity

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are retained and improved if the skills are practiced over an extended period of time. Repetition

on the other hand claims that neural plasticity is improved when the exercises or tasks

performed within one treatment session require high repetitions. Our patient is approved for 5

hours each week for a total of 12 weeks. We’d implement duration by having therapy cycle

between 4-5 days every other week. If the week involves 4 sessions, 3 of those days will include

one hour of therapeutic exercise, while the last day will combine one hour of exercise with an

hour of manual therapy and assessments (on every 8th visit). The next week will involve 5, one-

hour visits and focus primarily on exercises and tasks. For every exercise performed, they will

consist of high repetitions of 30 and over and number of sets dependent on clinical judgment.

The repetitions, resistance, or difficulty will increase progressively. We will implement both

within the Home Exercise Programs (HEP) that will be given and demonstrated to the patient

and caregiver. If we implement CMIT, we will give specific instructions on the expectation of

how long the patient will wear the restrictive device: 70% of awake hours. I find it important to

inform the caregiver of allowing independence at home. Intensity of the exercises both at home

and in the clinic will increase throughout the 12-week period. Consistency is the key when it

comes to rehabilitation for stroke patients and these principles will be addressed by allocating

at least one hour sessions of time multiple days a week in addition to including high-repetition

exercises in-out of the clinic.

The sixth principle, “Timing Matters,” refers to the various timeframes post-stroke that

different aspects of neural plasticity occur. There is a time period shortly after the stroke in

which a patient will see large learning curves and increases in neuroplasticity of those affected

regions are engaged. Therefore, I would implement treatment early on with this patient to

ensure the patient can achieve as many gains in functional ability as early as possible.

Addressing this principle, I will change the demands and task levels according to where they

are in this timeframe to boost outcomes.

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 The seventh principle, “Motivation Matters” explains that what a patient gets out of

therapy and how important treatment is viewed can largely affect the impact rehabilitation has.

It’s important to know the mental and emotional state of the patient prior to treatment as well as

what is important to them when implementing this principle. Communicating with the patient is

also very important within this principle whether it be explaining why we are performing a certain

exercise, giving encouragement, or just listening to his concerns. The tasks will be tailored to his

goals of returning to work as a plumber and performing everyday activities with his wife and

children. These techniques address this principle because they focus on keeping the patient in

the right mindset so as the patient improves, I can apply functional tasks that make his goals

more tangible and rewarding.

The “Age” of the patient makes the eighth principle of neuroplasticity. Our patient’s age

matters because neural plasticity tends to have a larger potential in younger patients than in

older ones. With our patient being 45 years old, it is important that implementation of treatment

is modified for someone his age. Therefore, it is crucial to know if the patient has any other

comorbid diseases to ensure exercises are not too strenuous on his joints, heart, lungs, etc. In

addition, one must be aware that progress may take a little longer than if I were to treat a

younger patient. This will address this principle because we are catering our treatment to

potential limitations and lagging someone his age may have preventing discouragement and/or

injury.

The ninth principle, “Transference” is also considered when dealing with patients of

neurological injury. “Transference” refers to the beneficial impact that one practiced skill or task

may have on improving the ability to perform similar ones. I would implement this by applying

exercises to complex tasks, complex environments, and adding disassociation into treatment to

help transfer to real-life settings. For example the fine motor and pinch-grip strengthening

exercises will be designed with the idea that he is a plumber and we want to benefit other

muscles and ROM within the hand. We will have him not only perform generic exercises with

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tools such as the Digiflex or Handmaster, but also having him practice unscrewing nuts and

bolts, reeling against or with gravity eliminated, and radio-unlar deviation with the Flexbar. We

can also challenge him by requiring him to hold a weighted ball at 90° shoulder flexion and

perform mini-oscillations and as well perturbations. Giving him exercises where he holds a

weighted dowel and supinates-pronates his arm can help him use a wrench again because it

involves a similar motion as well as incorporating grip strength. Using the rebounder with a

weighted ball can help him gain strength and coordination of his upper limbs as well as transfer

into playing catch with his children again. We can also apply functional electrical stimulation in

the beginning of treatment to attempt to restore that mind-body connection while performing

specific tasks with his affected limb. Many everyday tasks both in his line of work and his

household require the ability of disassociation between both upper extremities. Therefore,

having him use the Upper Body Ergometer, radioulnar deviation, and reeling will force him to

perform contradicting movements with both arms at the same time. Strengthening exercises will

not only enhance his ability to keep his arm up against gravity for prolonged periods of time, but

increase the load in which his affected arm can handle against gravity. These exercises

address this principle because the treatment will be applied in a sense that can be generalized

to the real world and will work toward him gaining independence at work and at home.

The tenth principle, Interference is also significant to keep in mind because while some

tasks enhance the patient’s ability to use those skills across various tasks, other exercises can

interfere with progress or reacquiring of other abilities. This would be if we only implemented

associative tasks to make it easier on our patient or gave too much feedback for every task. Our

patient may begin to develop bad habits to compensate for their deficit in ability. It is important

to address and correct these habits in therapy as well as make sure his functional assessment

scores are not reflecting his ability to perform these tasks in result of the adaptation, but rather

indication that his affected limb is improving. Our tasks will vary and we will try to keep the

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training environment similar to one he experiences when he performs those tasks. In addition,

we will require him to practice these tasks before applying electrical stimulation to prevent a

reduction in functional organization. By doing these things, we are addressing this principle by

forcing him to unlearn those compensatory techniques and require him to actively engage both

arms in different tasks such as what he would do in various everyday situations.