by Steve Kerschke, PT, and Michala Witas, PT

stroke qli_imageDesigning rehabilitation programming for individuals who have acquired brain injury can be an exciting and challenging process for therapists. The often extensive and diverse nature of these types of injuries can present unique challenges for a therapy team. The pinnacle of rehabilitation in such cases involves blending formal and functional approaches to create an immersive, real-world rehabilitation program.

Physical therapists today are well equipped with knowledge, skills, access to emerging research, and specialized equipment designed to assist in treating specific conditions or deficits. From a therapy perspective, treating most physical injuries or rehabilitation processes can appropriately be done in relative isolation. Rehabilitating a knee after an ACL repair surgery or a shoulder after a rotator cuff surgery is a process that can typically be addressed by a single experienced physical therapist on a limited outpatient basis. Rehab exercises can be conducted in a traditional therapy gym setting a few days per week, with the patient responsible for performing a few simple exercises at home between therapy sessions. Rehabilitation programming following an acquired brain injury, however, should almost always follow a much different approach

APPROACH TO HEALING MULTIPLE DEFICITS
After an acquired brain injury, a patient will often present with a global array of deficits, including those that affect cognition, vision, communication, memory, and physical function. Treating a diagnosis of this type requires a comprehensive, multidisciplinary, real-world treatment plan. Research supports a collaborative approach driven by licensed medical professionals but assisted by a support system that could include family, friends, or other health care providers. If this approach is accepted and implemented correctly, it is a blending of the physical/medical, educational, and emotional approaches to rehabilitation. In this sense, “real world” is intended to mean a natural environment that reflects, as closely as possible, the environment to which the patient will return after completing the rehabilitation program. A real-world environment should be realistic in all aspects and should model the naturally occurring challenges the patient will face in all areas of life.

Keeping in mind there are degrees of “comprehensive,” “multidisciplinary,” and “real world” rehabilitation, certain techniques and program designs are more effective in achieving optimal outcomes. Conclusions presented in recent research studies on the subject of neuroplasticity (the capacity of neurons and neural networks in the brain to change their connections and behavior in response to new information, sensory stimulation, development, damage, or dysfunction) provide guidance for how rehabilitation after a brain injury can be carried out most efficiently and effectively.

NEUROPLASTICITY AND THE ROAD TO RECOVERY
Following are three key principles of neuroplasticity that should be considered: 1) the importance of maximizing task specificity (a focus on functional skills training rather than general motor activity); 2) intensity (quantity of proper repetitions in one setting); and 3) repetition (quantity of consistent repetitions carried out over time). Looking at the rehabilitation process through the prism of these three tenets of neuroplasticity helps clarify which tasks or therapeutic activities a therapist will ask patients to perform and how a program might be designed to optimize their implementation and effectiveness.

Accessing the benefits offered by the brain’s ability to reroute signals can present a practical therapeutic challenge due to the intensity and consistency of activity that is required to produce results. Perhaps the most effective way of executing this program design is to take a real-world approach to rehabilitation. If this is carried out in an inpatient setting, capable of providing intensive 24-hour rehabilitation, practice and repetition are maximized while maintaining a focus on task specificity. Just as important, this type of program design also addresses the ever-present challenge of working with individuals with brain injury and enabling the generalization of skills from one setting to the next. Foundational skills are vital to long-term success, but it is important to remember that, at some point, the patient must make the jump into the real-world setting.

POWER OF PERSONALIZATION
One other advantage of designing and implementing a truly real-world approach to rehabilitation is the ability to capitalize on a patient’s individual identity and the motivating aspects of that person’s life. Incorporating meaningful and realistic activities and skills into a therapy regimen not only promotes neuroplasticity and generalization of skills, but also significantly increases patient ownership, compliance, motivation, and accountability.

Regarding the physical aspects of program development, one should consider the environment to which the patient will be returning, the specific physical demands throughout all aspects of the day, and the best avenue to achieve quality movement patterns without sacrificing repetition. To build an effective program, it is also critical to develop a clear vision of the outcome goal and work backward to develop a road map for getting there.

CASE STUDY
Consider the following case: an individual with aspirations of attending a vocational trade school, who sustained both physical and cognitive deficits due to a brain injury. The nature of a trade school would be physically challenging on many levels. Standing for long periods of time, along with bending, squatting, and lifting activities, would be core activities throughout this patient’s day. Additionally, he would be required to manipulate a variety of tools and hardware to successfully complete the program.

In this particular case, several foundational skills were addressed with the goal of moving quickly from a formal to a functional setting. Body weight support treadmill and elliptical training was completed. Due to knee/ankle instability and deficits in strength and motor control, a foot drop system also was utilized. The foot drop system was used in all aspects of the patient’s program, formally and functionally, in order to reinforce specific motor patterns in the lower extremity during standing and gait-related activities. Other technologies that can offer therapeutic support for limbs affected by stroke include the use of braces and orthoses for upper and/or lower extremities.

Early in the process of these therapies, physical therapists were able to incorporate therapist-driven challenges such as visual scanning, carrying weighted objects, and dual-task training exercises to simulate challenges the patient will face in a more functional environment. Reintegration into a familiar and motivating environment was the cornerstone of the patient’s program. In addition to basic daily routines and participation in formal therapy sessions, therapists worked with the patient to set functional training goals that could be achieved through the completion of meaningful activities. To return successfully to the community, some patients may need to overcome balance issues, such as those caused by the effects of stroke on the vestibular system. Binocular goggles engineered to provide objective data regarding abnormal eye movement can be a tool that is useful in assessing vestibular conditions among stroke patients, and help return them to function confidently in the community.

MOVING FROM THERAPY INTO THE REAL WORLD
Given the patient’s strong interest in automobile repair, regular visits to an auto body shop were arranged. The purpose was to immerse the patient in a familiar environment where he would be presented with natural opportunities to apply foundational skills. Upper extremity strength and motor coordination were addressed through manipulation and use of tools such as wrenches, screwdrivers, and power sanders. The use of these and other related equipment provided ideal opportunities to address general and fine motor strength and coordination.

Other shop-related responsibilities, such as raising the hood to access the engine, maneuvering under the car on a creeper, and walking and carrying car parts, were incorporated to address overall functional mobility and balance. Initially, the environment was manipulated (ie, parts were moved to an open area) to allow for gross motor functioning, and the patient required significant hand-over-hand support to complete these activities. As the patient improved, the environment was adjusted to reflect the tight spaces often found in auto body shops, and support was faded over time to gradually increase demands. Time spent at the shop also was increased gradually to reflect the patient’s daily schedule and work load.

Therapists also arranged for the patient to attend classes at a local college to determine his ability to access the entire campus and surrounding buildings. From an endurance standpoint, the patient would need to be able to ambulate with a full backpack from one end of campus to the other. Uneven terrain (ie, inclines and declines, cracks in the sidewalks, and curbs) as well as the steps located around campus would present common obstacles. Details, such as carrying a tray in a cafeteria filled with people, grabbing a book off of the shelf at the library, and carrying a laundry basket to the washer and dryer located in the basement of a dorm, also were considered.

PERFORMANCE AND FEEDBACK
These visits to the shop and college campus were a combination of assessment and training sessions, and information from these visits also was used to develop a more complete formal therapy program. More importantly, some of these intricate details may have been overlooked, if they had not been revealed during trips to these two real-world settings.

When working with individuals who have sustained brain injuries, treatment plans will vary greatly. However, in most cases of moderate to severe brain injury (including traumatic, anoxic, stroke, and other modalities of acquired brain injury), most patients will reach a point, following acute hospitalization, where they are medically stable enough to progress beyond the somewhat restrictive hospital setting and may be able to benefit from specialized posthospital rehabilitation.

Inpatient, posthospital settings can be well suited to offer creative and individualized 24-hour real-world programming; however, creating and executing a rehabilitation program as described in this article requires a team approach, where therapists actively work to empower and teach others to truly implement this model. In each setting and during each activity discussed here, every health care professional, family member, and community volunteer was trained to provide the appropriate level of support to adequately challenge the patient while promoting positive repetition of ideal motor patterns to encourage neuroplasticity.

Although a 24-hour, real-world rehabilitation approach may be ideal, there exist very few rehabilitation providers that are able to offer this type of intensive, specialized programming. In instances where there are barriers to accessing this level and intensity of rehabilitation, consideration of the principles discussed above can still be applied, even in less ideal environments, to optimize long-term outcomes at all levels of care. RM

Steve Kerschke, PT, director of therapy services at QLI, completed both his undergraduate degree in exercise science and his master’s degree in physical therapy from Saint Louis University. Kerschke joined QLI in 2005 as a physical therapist and became director of therapy services in 2013. He consults internationally with brain and spinal cord injury rehabilitation providers as a CARF surveyor.

Michala Witas, PT, director of therapy services at QLI, is a clinical leader in QLI’s posthospital rehabilitation program, specializing in comprehensive rehabilitation services for individuals with acquired brain or spinal cord injuries. As director of therapy services, Witas oversees patient programming, family education, and staff training. For more information, contact [email protected]