APPLICATION OF A COMBINED REHABILITATION APPROACH FOR A

CHRONIC STROKE PATIENT WITH GAIT IMPAIRMENTS: A CASE STUDY

Presented in Partial Fulfillment of the Requirements for the Degree of Doctor of Physical

Therapy in the

Graduate School of The Ohio State University

By

Allison N. Weeks

*****

The Ohio State University 2014

Doctoral Examination Committee: Approved by

Dr. Alexandra Borstad, PhD, PT, NCS

Dr. Deborah K. Kegelmeyer, DPT, MS, GCS

Dr. Marka Gehrig, PT, DPT

___________________________ Advisor School of Health and Rehabilitation Sciences

ABSTRACT Background and Purpose: Stroke is one of the leading causes of disability in the United

States, leaving the patient with residual deficits including: gait abnormalities,

hemiparesis, and impaired cognition.1, 2 Neuroplastic changes in the brain have been

found to occur most prominently in the first 3 months, and then progressively decline

through the 6 month time frame.3 Newer research has illustrated improvements in

functional outcomes occurring after the 6 month period when exposed to ideal

environment and interventions based on the motor learning theory.4 The purpose of this

case report is to describe a combined task-oriented and neurodevelopmental approach

implemented in an outpatient physical therapy setting for gait improvements in a patient

post stroke that did not receive acute or sub-acute rehabilitation services. Case

Description: The patient, J.O. was a 68 year old African American male presenting with

deficits from a stroke approximately 6 months prior. J.O. had generalized right-sided

weakness and impaired balance, which affected his ability to ambulate without an

assistive device, and negotiate stairs and obstacles without increased risk of falling;

therefore, preventing him to safely live alone or return to work as a professional cab

driver in New York. Intervention: The patient attended 11 45-minute sessions on the

course of 8 weeks. Physical therapy interventions included: a sequence of stepping

interventions, over-ground gait training, therapeutic exercises consisting of progressive

open and closed chain resistance exercises targeted for lower extremity strengthening and

flexibility, balance exercises, and cardiovascular endurance training. Outcomes: The

patient exhibited a minimal clinically important difference (MCID) on the Berg balance

scale (BBS), and a non-clinically important difference on the 6-minute walk test

(6MWT). The patient regressed by 0.2 m/s with the 10-meter walk test (10MWT), and

gait abnormalities persisted. Conclusion: This study describes there may be potential to

improve functional status of a chronic stroke patient, specifically balance and endurance,

with the combined therapy approach, but more research is required.

INTRODUCTION

Stroke is the fourth leading cause of death and one of the leading causes of disability

in the U.S. Ischemic stroke accounts for 87% of all strokes; the remaining 13% are

hemorrhagic.1 The American Heart Association has classified the risk factors of stroke in

two categories, uncontrollable, including age and race, and controllable. The risk of

stroke doubles with each decade after 55 years of age. African Americans have twice the

risk of mortality and twice the risk of first strokes compared to Caucasians. Controllable

risk factors include: hypertension, hyperlipidemia, atrial fibrillation, high cholesterol,

diabetes, atherosclerosis, tobacco and alcohol use, physical inactivity and obesity.2

There are many physical impairments resulting from stroke. According to the

Framingham Heart Study, the most common impairments at 6 months post stroke

included: hemiparesis, gait dysfunction requiring an assistive device, cognitive deficits,

depression, aphasia, and dependence with activities of daily living (ADLs).5 Duncan et al.

found that walking ability is impaired in more than 80% of post-stroke patients.6 Most

stroke survivors, 60-85%, learn to walk independently by 6 months post stroke; however,

gait abnormalities persist past this time, thus, one of the major goals of outpatient

rehabilitation is restoration of gait.8,9,10

A normalized gait pattern is comprised of dynamic interactions between the

cerebral cortex, brainstem, cerebellum, and the spinal cord. The spinal cord, comprised of

central pattern generators, allow for the basic locomotion stepping pattern, as well as

descending pathways that stop or trigger walking. The role of the cerebellum, brainstem,

and cortex are fine motor control and coordination that is involved in the gait cycle and

negotiation of the environment. In patients with a stroke, these areas of the brain can be

impaired, producing asymmetrical gait abnormalities and loss of the dynamic interactions

between gait and the environment.11 In addition to the gait asymmetry from the cerebral

cortex, there are secondary impairments contributing to the observed gait dysfunction,

including: muscle weakness, incoordination, pain, spasticity and decreased balance. Gait

training interventions, therefore, need to address motor control, muscle strength and

balance in order to improve locomotion.6, 11

Several prognostic factors have been shown to have significant correlation with

stroke recovery. A systematic review found that time of initiation of therapy, duration,

intensity, and location of rehabilitation are linked with functional outcomes and mortality

rates in patients post stroke. Rehabilitation initiated within 15 to 30 days in a

multidisciplinary acute rehabilitation setting was found to have better outcomes, and

shorter hospitalization stay regardless of severity of stroke.5, 12, 13 A study by Salter et al.

found that delayed rehabilitation, treatment initiated greater than 30 days after the stroke,

was associated with longer hospital stays and decreased adequate functional recovery due

to decreased cortical reorganization.46. In regards to duration, it was found that brain

plasticity and functional recovery can significantly change upwards of 6 months with

rehabilitation services. Higher intensity levels of rehabilitation were associated with

improved ADLs and lower degree of disability.14 A 1 year study by the Stroke Unit

Trialists’ Collaboration found that the patients who had shorter hospitalization and

increased independence were those who received inpatient rehabilitation in

multidisciplinary stroke specific rehabilitation centers compared to standard inpatient

rehabilitation.12 Thus, the rehabilitation received in the first several months is a significant

prognostic factor of functional recovery and neurologic recovery.

Most literature to date has found that spontaneous neurological recovery occurs

during the first 3 months after the stroke, and the rate of recovery decelerates in a

predictable phenomenon within 6 months; however new literature is showing that

recovery can occur after the 6 months although not as significant as the early stages.3, 18

Neurological recovery occurs early in affected areas of the brain with resolution of edema

and recirculation, lasting up to 4-6 weeks. Nudo et al. found that diaschesis, a state of

depressed neurological function from a sudden interruption in part of the brain, occurs

early after injury, and is a suppression of surrounding areas that are connected with the

affected area. The resolution of diaschesis is associated with the return of neuron function

if the connection to the injury is intact.16 Central nervous system (CNS) reorganization

that occurs later in the recovery stage includes: neurotransmitter alterations, unmasking

silent synapses, and synaptogenesis; all of which can occur months after the stroke.17

With the use of functional magnetic resonance imaging (fMRI), there is increased

opportunity to study the neuroplastic changes in the human brain.18 The evidence from

several fMRI studies illustrates the use of massed practice, involving high number of

repetitions in a session, create larger areas of activation. Thus, in rehabilitation, massed

practicing can yield a more complete neurological recovery.18

Another contributor to neurological recovery is motor learning.4, 12,1 5 Motor

learning focuses on repetitive practice with manipulation of specific variables in tasks

that require relearning in order to induce changes in the brain reorganization.19 Motor

learning can increase synaptic connections and promote synaptogenesis. Animal research

states that axonal sprouting and synaptogenesis appear to be associated with recovery,

and in order for reorganization to occur, there must be secondary cortical connections

with the damaged area.19

Several intervention approaches are commonly utilized in stroke rehabilitation.

One rehabilitation approach is task oriented training, which is based on active practice of

specific functional motor tasks with appropriate feedback that would promote motor

learning and recovery.4, 15 Task specific training involves functional repetitive tasks

performed in a skilled environment that are also meaningful to the patient.38 Studies have

shown that task specific practice must happen in order for motor learning to occur.4, 6, 15, 21

Another rehabilitation technique commonly utilized in stroke rehabilitation is the

neurodevelopmental method.15 This approach focuses on the patient receiving

proprioceptive neuromuscular facilitation, and on moving the patient through the desired

motions, with the patient being more of a passive recipient and the therapist being the

main active decision-maker. The latest Cochrane Review on stroke rehabilitation states

that there currently is no single approach to rehabilitation that is more effective than

another, and suggests a mixed approach to treatment.15 In a study by Belda-Lois et al., the

motor learning approach was primarily utilized with some aspects of the

neurodevelopmental approach, and found significant recovery in the patients compared to

the control.11

The purpose of this case study is to describe a combined rehabilitation approach

implemented in an outpatient physical therapy setting for gait in a patient post-stroke who

did not receive acute or sub-acute rehabilitation services and to describe his outcomes

from treatment.

CASE DESCRIPTION

This case study focuses on the physical therapy interventions for J.O. a 68 year

old African American male post left CVA, who gave consent to use his information.

Because J.O. had not received any rehabilitation during the first six months after his

stroke, when most spontaneous recovery occurs, the patient was a good candidate for a

case study to analyze the effects of a combined treatment approach in the chronic phase.

According to the Guide to Physical Therapist Practice, stroke corresponds with the

preferred practice pattern 5D: impaired motor function and sensory integrity associated

with nonprogressive disorders of the central nervous system- acquired in adolescence or

adulthood.20 The International Classification of Functioning, Disability and Health model

(ICF) was utilized in order to implement an individualized treatment, identify primary

function resulting in gait dysfunction, select appropriate outcome measures, and identify

personal and environmental factors that may influence treatment outcomes (Figure 1).20,21

Figure 1: The International Classification of Functioning, Disability and Health model of functioning and disability.20

Examination

History

Subjective: The evaluation was performed 5/13/14 at the outpatient clinic. The

patient was referred to the clinic after a fall he sustained the previous week at his son’s

apartment. He sought immediate treatment at the emergency room with primary

complaints of shoulder and elbow pain. The patient had a left ischemic cerebrovascular

accident (CVA) approximately six months prior to evaluation date while visiting his

hometown in Africa. Upon evaluation, he presented with reports of: increased confusion

and decreased memory, required use of standard cane for ambulation, limited standing

and walking endurance, and inability to return to work due to the weakness in his right

leg and arm. J.O. reported pain in the right shoulder only when reaching past 90°, none in

his elbow. J.O. also reported “stiff, achy” low back pain, rated a 6 out of 10 on a pain

rank scale, which worsened with prolonged sitting or standing, and had been occurring

prior to the stroke. He did not seek out therapy or any type of interventions for the

chronic low back pain or stroke. The patient’s son reported that J.O. might have had a

small stroke or transient ischemic attack (TIA) a few years ago resulting in a similar

presentation, but ultimately resolving. J.O.’s goal was to improve ambulation without an

assistive device and return to the level of independence before his initial stroke including

living alone in his home in New York independently, and returning to work.

The patient previously lived in New York City, working as a professional cab

driver and was independent with all ADLs. Past medical history included: TIA, benign

prostate hyperplasia, hypertension, past right clavicle fracture, and right femur fracture

with open reduction internal fixation. X-rays of the right shoulder were taken on 5/2/14

while in the hospital, showing no evidence of fracture, but fusion of the

acromioclavicular and coracoclavicular joints. Lumbar X-rays were also taken, showing

mild rotary scoliosis concavity to the right and mild disc space narrowing. CT scan

showed no acute process, however there was remote ischemic changes in left parietal

lobe and subcortical white matter with mild diffuse cerebral cortical atrophy. Current

medications included: Aspirin, Losartan, Labetalol, Nifedical, Simvastatin, Doxazosin

and Mesylate. The patient reported no allergies, and no falls since the initial fall that led

to his admission.

Objective: The patient was alert and oriented, able to follow 3-step commands. A

language barrier with comprehension of what the therapist said, and expression of his

feelings and goals was noted due to English being a secondary language. His

cardiovascular system was within acceptable levels, with pre-hypertensive blood pressure

of 130/76 mmHg, pulse 95 beats per minute, and oxygen saturation 99%. J.O.’s

integumentary system was intact, with no scars or discoloration observed upon

evaluation. The patient denied reports of numbness or tingling, and a touch screening was

intact in the lower extremities; therefore, a comprehensive sensory assessment was

forgone secondary to time constraints.

The neuromuscular system had noted impairments consisting of decreased inter-

limb and intra-limb coordination of the right side during coordination tests, including:

rapid supination to pronation, fine finger movements, and heel-to-shin tests. J.O. had

decreased ability to utilize specific movements out of synergy in order to perform

functional motor task, i.e isolating elbow flexion to take a drink of water. The modified

Ashworth scale has adequate intra-rater reliability for measuring tone in the lower

extremity for the stroke population; however, has poor inter-rater reliability, but is

currently the accepted primary means for assessing spastcity.22, 23 Tone was graded as 1+

on the modified Ashworth as resistance was noted with right knee flexion into extension,

indicating slight hypertonicity.

Manual muscle testing (MMT) is the most commonly utilized tool for

documenting strength impairments. A literature review performed by Cuthbert et al.

found overall there is adequate reliability and validity in MMT which improves with

more experienced clinicians.24 The musculoskeletal system was impaired on his right side

only, with most weakness in the hip and ankle (See Table 3 for MMT scores for right

lower extremity). The right upper extremity had adequate strength (3/5) for motions less

than 90° of shoulder flexion secondary to pain. In the lower extremity, he had decreased

pliability in bilateral hamstrings, measuring 50° on left and 60° on right with passive

knee extension.

Bed Mobility and Transfers: The patient was independent with rolling on a mat,

but this required significant effort. J.O. was able to perform sit to stand transfers

independently but demonstrated decreased weight shift on the right side, and increased

reliance for upper extremity support. Further functional analysis included: stooping to

retrieve objects from a lower cabinet in a kitchen and recovering to standing with the

object, which he performed with stand by assist due to imbalance; abnormal synergy

patterns with both flexion and extension of the right upper extremity was observed while

performing the task.

Stairs: The patient was able to reciprocally ascend and descend 4 standard 8”

steps with use of a handrail. When ascending and descending without the use of a

handrail, he demonstrated impaired balance and required close stand by assist. Weak

eccentric gastrocnemius and soleus, and quadriceps were noted during descent of the

stairs, along with excessive right lateral trunk flexion, resulting in an observed lack of

tibial control and decreased safety.

Posture: Seated posture revealed forward shift of head and shoulders, medial

winging of the right scapula with scapular elevation and downward rotation, and

decreased lumbar lordosis. Standing posture revealed similar abnormalities.

Gait analysis: The patient typically used the assistance of a standard cane to

ambulate, but upon evaluation, the therapist deemed it safe to perform gait analysis

without an assistive device. J.O. ambulated with stand by assist, demonstrating postural

dysfunction as observed in standing postural assessment, decreased right stance stability

with decreased left step length, and decreased right foot clearance. Initial contact was

made with the right lateral forefoot, foregoing the ankle rocker component in the loading

response. Right hip abductor weakness with left hip drop and lateral trunk lean to the

right were present during right midstance phase. During right terminal stance, the right

hip did not achieve adequate hip extension, and during the preswing phase, there was a

lack of concentric plantar flexion component to achieve an adequate push off.

Table 1: ICF model specific to J.O. ICF Category Patient description Health condition Left CVA Body functions and structures Decrease muscle strength (especially hip abductor,

extensor, plantarflexor, dorsiflexor, hamstring and

quadriceps), decrease control of voluntary

movement/synergistic flexion and extension pattern,

decrease cardiovascular fitness, mild spasticity, , adequate

PROM

Activities Decrease ambulatory speed and endurance, decrease

ability to ambulate on various terrain, decrease balance,

decrease ability to reach overhead, able to ambulate

with cane, ascending and descending stairs with assistive

device and handrail

Participation Unable to perform IADLS in order to live independently

without family support, unable to drive, unable to work

due to not driving, unable to ambulate safely without

AD in community

Personal Factors Decrease self efficacy, increased motivation, cultural

barrier, minimum income, previous CVAs

Environmental Home alone during day on second level home with son,

home in NY city with no family support.

Tests and Measures:

The patient’s gait speed was 1.1 m/sec without use of assistive device, which

places him in the “limited community ambulatory” category.29, 30 Self-paced gait speed is

the most common outcome measure for gait training strategies, and has been linked with

level of mobility.25 The 10 meter walk test (10 MWT) was used to assess gait speed, and

is highly recommended by the STROKEdge task force for patients with stroke due to the

evidence of high reliability and validity in several studies with post stroke population.25-27,

47 The 10 MWT has been considered a predictor for prognosis for ambulatory return.

Ambulating without an assistive device at a rate of less than 0.4 meters per second

(m/sec) is predictor of household walking, 0.4-0.8m/sec predicts limited community

walking, and >0.8 m/sec predicts unlimited community walking with self-selected pace.20

A study found that mean gait speed is 0.53 m/sec for chronic stroke patients compared to

1.3 m/sec in healthy adults.49

In the 6 MWT, the patient ambulated 312 meters with post vitals similar when

compared to pretest vitals. The 6 MWT is the second most commonly utilized test to

assess gait, and is also recommended by STROKEdge for outpatient and inpatient

rehabilitation to determine functional walking capacity.31, 32, 35, 47 This submaximal test has

excellent validity and reliability in the stroke population.32 Newman et al., found that the

ability and time to walk 400 meters was a valid predictor of mortality, cardiovascular

disease, and mobility disability for community dwelling adults.31 A study found that

subacute and chronic stroke patients ambulated on average 200 - 300 meters compared to

the average of 400 meters in healthy adults in the 6 MWT.33 Most standard tests utilize a

track with minimal turns; in the clinic we had to utilize a figure eight track for patient

safety thus potentially decreasing the validity of standardized measures, but maintaining

intra-rater reliability.

J.O. scored at a 35 on the BBS, placing him in the “moderate fall risk” category

(Table 5). The BBS is another outcome measure that is highly recommended by the

STROKEdge task force for chronic stroke and outpatient rehabilitation, and has shown to

have high reliability and validity in assessing fall risk in the stroke population.34, 47 A

systematic review performed by Blum et al., found that the BBS has excellent internal

consistency, interrater reliability, intrarater reliability, and test-retest reliability with the

stroke population.34 The total score attainable is 56; 41-56 is considered a low fall risk,

21-40 a medium fall risk, and 0-20 is high fall risk.34

The Dynamic Gait Index (DGI) was not performed during the initial evaluation

due to time constraints, however, was utilized later in the plan of care. The DGI is a

highly recommended by the STROKEdge as an outcome measure for dynamic balance,

and has high reliability with the stroke population.35, 47

Evaluation, PT diagnosis, Prognosis

The patient was modified independent for basic functional mobility skills, with

notable gait and balance impairments. Decreased scapular mobility prohibited appropriate

scapulohumeral rhythm and contributed to pain with overhead reaching. Gait was

impaired with decreased right stance stability, decreased right foot clearance and

decreased terminal knee extension with dorsiflexion, with impaired quality, speed and

balance. He was at increased risk of falls based on his BBS score. ICD-9 codes utilized

included: 438.21 Hemiplegia- Dominant Side, 781.2 Abnormality of gait.20

J.O. had good rehab potential to return to previous level of independence based on

not yet having the opportunity for neuroplastic changes that could be promoted in a

rehabilitation setting. The patient was also highly motivated to attend therapy because of

his desire to move back to New York and work again. He was living with his adult son,

who was able to offer some assistance to the patient. Unfortunately, the son worked

during the days and was unable to take his father to appointments, thus making

transportation a barrier. Recommended consults included speech therapy for impaired

cognition, and social work for financial and transportation problems. Occupational

therapy (OT) was already involved in the plan of care initiated by the physician. J.O. was

scheduled with PT, OT, and speech therapy 2 times a week for 8 weeks. The patient’s

goals were to return to premorbid level of independence. The therapy goals addressed

strength, balance, and gait, and comprised of the following:

Long-term goals (8 weeks):

1. Patient will ambulate independently in community (curb, stairs, terrains,

grades) with appropriate speed (1.2m/sec) without risk of falls (loss of balance),

as seen by negotiation in the outside grounds of the clinic.

2. Patient will demonstrate appropriate and adequate strategies to maintain and

regain balance while performing functional activities in standing, as measured

with a BBS score of 48/56 indicating a low fall risk.

3. Patient will demonstrate increased strength in the lower extremity as seen by

achieving adequate stance stability on right LE for normal step length 75% of

steps without assistive device as observed by a more symmetric gait.

4. Patient will reciprocally ascend/descend a flight of stairs without handrail with

supervision and minimal cueing.

5. Patient will achieve right hip extension in terminal stance in order adequately

set-up for the push-off and create a more efficient gait.

Short-term goals (5 weeks):

1. Patient will demonstrate an increase of 5° of active range of motion in right

gastrocnemius/soleus complex in order to achieve adequate tibial advancement in

gait.

2. Patient will demonstrate ability to complete 10 minutes of continuous

cardiovascular activity, on seated cardiovascular device with rate of perceived

exertion (RPE) <14 and stable vital signs.

3. Patient will demonstrate independent carryover of home exercise program for

strength and balance per patient report.

4. Patient will initiate use of affected UE for support and balance independently in

sitting and standing activities with minimal verbal cueing.

5. Patient will increase bilateral hamstring passive knee extension (PKE) by 10 ̊ in

order to improve functional ability.

INTERVENTION

The physical therapy sessions spanned along the course of 8 weeks. J.O. was only

able to participate in 11 of the 16 expected visits secondary to medical and transportation

reasons. A typical session with this patient included initial cardiovascular endurance

exercise on the Nu-Step, stretching and progressive resistive strengthening (PREs) for the

impaired muscle groups, task specific exercises at stairs or over ground gait training with

appropriate progression as needed (See Table 2 for summary of treatment). One to two

minute breaks from exercise were taken after 10-12 repetitions were performed, upon

patient request, when form began to decline significantly, or when warranted by

physiological responses to the intervention. Physiological measures that would cease

exercise were based on the American Heart Association guidelines, which included:

blood pressure that increased 20mmHg systolic, 10mmHg diastolic, heart rate above

100bpm, increased respiration rate with shortness of breath, or patient reports of

lightheadedness and/or dizziness.48 The tenth visit, the patient’s blood pressure was

irregularly high and in dangerous levels for stroke reoccurrence despite being

asymptomatic. Upon questioning by the physical therapist, J.O. reported he was not

taking his medication regularly due to not having the financial means of obtaining a refill

for the prescriptions. The session was discontinued until follow-up made with primary

physician, education was provided in the clinic regarding the importance of taking

medication as prescribed, and the EMT was called to take J.O. to receive immediate

treatment.

Functional task-oriented activities with NDT facilitation were the focus of the

sessions. An example of a task oriented intervention to improve right stance stability was

having the patient would perform a sequence of stepping at the stairs. Beginning simply,

the patient would step and tap the 1st step with his left foot. This was progressed by

stepping and pausing on the 1st step, requiring J.O. to sustain the stride position. This

further progressed by stepping to the 2nd and 3rd step, which increased the time spent in

single leg support. Also, decreasing the UE support increased the demand on the right

lower extremity for balance and strength. While performing these tasks, facilitation was

given at maximal to moderate intensity to the impaired right hip abductor and extensors

and abdominals. This facilitation in addition to verbal cues provided J.O. with the

necessary feedback to engage the muscles while performing the activity. As the patient

became increasingly independent in engaging the targeted muscles, the intensity and

frequency of the external feedback decreased in a faded manner. To allow for carryover

to gait, overground gait training was performed at the end of each session. The patient

was given similar verbal cueing and facilitation as the stance training, and similar

activities were performed, such as stepping over objects with his left during ambulation

in order to prolong stance time on the right.

Table 2: Summary of Treatments for J.O.

Findings Treatment Rationale Time (minutes)

Repetition/Threshold

Visit 2: Decrease cardiovascular endurance Decrease PROM in BL hamstring and gastrocnemius/soleus complex Right hip flexion, abduction weakness Decreased ground clearance on right swing phase during gait

NuStep Supine hamstring stretch with belt, standing gastrocnemius and soleus stretch against wall Clamshells, unable to perform sidelying abduction due to weakness. Straight leg raise Trial Swedish AFO Over ground gait training with AFO and patient education

Increase CV endurance Strengthening the hip abductors, hip flexor DF weakness and tightness in gastrocnemius- soleus complex contributed to decreased ground clearance and posed as fall risk. AFO addressed problem temporarily for therapist to focus on larger problems.

3 5 5 25

Time, vitals, RPE scale 2x30sec each stretch 2x10 or patient tolerance Patient tolerance

Visit 3: Decrease CV endurance Decreased stance time on right side with gait Decreased trunk stabilization during gait

NuStep Right stance progression at stairs. Progressions as appropriate (decreasing UE support, increasing step height, various directions) Gait training on level surface with upper extremity close chain, pressing an object against his right side.

Increase CV endurance Increase patient comfort with stance on right via performing task of stepping with left. Pressing the object activated core muscles (Quadratus lumborum, obliques, and paraspinals and transverse abdominus), and

5 15 15

RPE, vitals, time x15, or patient tolerance, and observation of compensation or fatigue Patient tolerance, observation of compensation or fatigue

assisted in preventing the trunk lean

Visit 4-5: Decrease CV endurance Decrease stance and terminal stance on right side Poor abdominal and gluteus medius activation during step training Gait with decreased midstance and terminal stance on right with right trunk lean and Trendelenberg.

Nustep Lunges, stepping forward with left to achieve terminal stance on right. Progressed by decreasing UE support. Right stance progression at stair, patient step to 2nd and 3rd step with left. Verbal cueing and tactile cueing given by therapist during above the interventions. Tactile cues on the abdominals with therapists’ left hand and right hip abductor and extensor with therapists’ left hand Gait training over ground with same verbal and tactile cues given with stance progression interventions. Stepping over object with left during gait. Patient push against hand of therapist at 60*

Increase CV endurance Lunge is exaggerated step, increased patient comfort and confidence with taking larger steps Stepping to 2nd and 3rd step required increased stance time on right, and required achieving terminal stance. Cueing to help provide feedback to patient to engage these muscles during the activity To apply the interventions directly to gait for carryover. Pushing at highest point without pain on right side engaged the core and decreased the trunk lean during ambulation

5 10 20 10-20

RPE, vitals, time Patient tolerance and observation of compensation or fatigue.

Visit 6-7: Weakness with hip flexion, extension, and abduction on right side Hip drop with stance exercises External rotation weakness with MMT

Multidirectional stepping BL with resistive band Stance exercise with side steps, progressed with increased heights and UE support. Added multidirectional pivoting movements with left foot on roller

Resistive band steps helped to functionally strengthen the targeted muscle groups Side steps focused on abduction and adduction strengthening and stability. Pivoting requires both abduction and external rotation.

5 15-20

X10 BL each direction. Patient tolerance or observation of compensating pattern.

Visit 8-9: Increased reports of back pain and poor transverse abdominal activation

Supine transverse abnominus (TA) activation progression.

Supine is easiest position to activate TA. Progress by adding UE and LE

10

2x10

Decrease core activation in standing Decrease core activation while ambulating

Wall squat with ball while performing pelvic tilts. 1# ball overhead reach and diagonals with TA activation Gait training overground while squeezing ball together, tactile cues at abdominals.

motion to increase difficulty while maintaining activation Standing is more functional and more carryover into gait. Tactile cueing along with squeezing the ball helped patient to activate and sustain the contraction.

15-20 15

Patient tolerance Patient tolerance

Bilateral (BL), Rate of Perceived Exertion (RPE), Ankle Foot Orthosis (AFO)

PATIENT EDUCATION:

The patient was issued a home exercise program (HEP) the second visit after

demonstrating the exercises in the clinic with supervision. J.O. and his son were both

educated on the HEP and issued a handout with standard pictures and descriptions of the

exercises. Additionally, the son took pictures of J.O. performing the stretches and

exercises on his iPad® to provide further clarity of the exercises.

The HEP was modified throughout the span of treatment sessions, exercises

included: gastrocnemius and soleus stretching, piriformis and hamstring stretching, 4 way

hip, squats, and balancing in stride, single leg and tandem stances. Interventions at the

stairs would have been an ideal addition to the home program in the later sessions;

however, the patient did not have any private stairs at his home.

The patient was also educated on the ankle foot orthosis (AFO) and its wearing

schedule. The first day, J.O. was educated to wear it only for a couple hours, then to take

it off and perform a skin check. He was educated to not wear the AFO if he noticed any

skin irritations or sore spots on his foot. The son was also present to receive this

information. The patient was also educated intensively on the signs and symptoms of a

stroke, and the importance of seeking medical help if he was experiencing any of those

indicators.

OUTCOMES

A progress note was performed on the 11th visit, for reassessment purposes. The

patient showed an increase in strength in the lower extremity as shown by the manual

muscle test (Table 3). The same outcome measures were administered as the initial date

in order to determine improvements in function through minimal detectable changes

(Table 4). J.O. had a minimal clinically important difference in the BBS, with

improvement from 35 to 45 (MCID >3.8 points), which places him at a lower risk of

falling compared to his initial score (Table 5).34 However, the patient was still at an

increased fall risk based on the DGI score of 12.35 An improvement in his 6 MWT for

cardiovascular endurance was observed, however it was not clinically significant (MDC

>36.6). His gait velocity declined from initial to reassessment date (Table 4). In

reassessing the short-term goals, the patient achieved increasing bilateral hamstring and

heel cord ROM, and was progressing towards using the affected UE for support and

balance. The patient did not meet the HEP carryover based on subjective report, and did

not consistently meet the 10 minutes of cardiovascular activity with stable vitals. Long-

term goals, the patient was progressing towards, however did not meet the set gait speed

of 1.2m/s (0.9 m/s at reassessment), the desired BBS score of 48 (45 at reassessment),

and still required close supervision when ascending and descending stairs. The patient

still required moderate to maximal external feedback in the form of tactile and verbal

cueing with the stair negotiation and the desired achieving stance stability on the right

side.

The gait assessment continued to show some excessive lateral trunk flexion to the

right during right midstance and decreased terminal stance, but improved compared to

initial assessment, especially with no observation of Trendelenburg sign, based on

therapist observation. Continued impairments in gait included: poor neuromuscular

activation of the core, lacking initial contact and therefore negating the forefoot rocker,

and decreased hip extension in terminal stance. The patient exhibited guarded positioning

with left upper extremity, and mild posturing of the right limb in flexion synergy. The

plan of care was to continue therapy to further progress interventions and work towards

meeting patient’s goals.

Table 3: Manual Muscle Test of Right Lower Extremity (_/5) Initial and 11th visit Initial Progress post 11th visit

Hip Flexion 3/5 5/5 Hip Extension 2/5 2+/5 Hip Abduction 2/5

Unable to isolate 3-/5

Knee Flexion 3/5 3+/5 Knee extension 4/5 5/5 Ankle Dorsiflexion 3/5 3+/5 Ankle Plantarflexion 2/5 4+/5

Ankle Evertors 2/5 2+/5

Ankle Invertor 2/5 3/5

Table 4: Neuro Outcome Measures for J.O. at initial evaluation and 11th visit Tests Initial 11th visit Berg 35 45* 10 MWT 1.1 m/s 0.9m/sec 6 MWT 312 meters 335 meters DGI Not assessed 12 *Indicates met the minimum clinically important difference for that measure

Table 5: Berg Balance Scale for Patient at evaluation date and re-evaluation BERG Initial 11th visit Sit to Stand 4 4 Arise 4 4

Sit Unsupported 4 4

Stand to sit 4 4

Transfer 4 4

Stand Unsupported Eyes Closed 3 4

Stand with feet together 3 3

Reach forward in standing 1 4

Picking up object from standing 3 3

Turning to look 1 4

Turning 360 Turn 1 2

Alternating foot on step 2 2

Stand unsupported one foot in front 0 2

Standing on one leg 1 1

DISCUSSION

There is evidence to support the use of a mixed rehabilitation approach in the

treatment of chronic stroke patients, despite not having an overall consensus in the

literature.9, 38 The studies that have evaluated the effectiveness of outpatient rehabilitation

and functional recovery for stroke patients illustrate that functional changes can be made

after the 6 month time frame with the use of a rehabilitation approach that involves

skilled, massed practice.13, 15, 19, 21, 43 The focus of this case study was to describe a

combined rehabilitation approach implemented in an outpatient physical therapy setting

for gait improvements in a patient who did not receive acute or sub-acute rehabilitation

services for his stroke deficits.

The benefit of providing a combined task oriented and NDT approach was that

the patient was able to have the repetition of a meaningful task, while receiving external

feedback through facilitation. In theory, task specific interventions were used to promote

motor learning and overcoming the learned compensatory strategies through skill

acquisition and massed practice.6, 41 Because the patient had poor body awareness, there

was the possible benefit from the facilitation and verbal cueing. With a verbal cue to slow

his gait speed and facilitation at the right hip abductor and extensor, J.O. had a more

symmetrical gait and was able to achieve adequate hip extension in terminal stance and

heel strike at initial contact. Additionally, there was a notable decrease in lateral trunk

flexion when J.O.’s right upper extremity was maintaining an isometric contraction, such

as pushing against the physical therapists’ hand, as this provided the necessary feedback

to activate the core stabilizers.

As discussed above, the patient was able to achieve a more efficient and

symmetric gait pattern during the sessions with the assistance of cueing from the physical

therapist, however this did not carryover during the gait re-assessment. Without the

facilitation, J.O.’s gait assessment at the 11th visit showed similar gait deficits as the

initial day. Due to one of the primary focuses being on functional hip strengthening, the

patient did exhibit more hip stability compared to the evaluation date, as shown by the

absent Trendelenburg sign. Lateral trunk flexion was still observed, with right upper limb

posturing, which could be due to not being addressed in the sessions as frequently as the

primary hip impairments.

Within the 8 weeks between the evaluation and reassessment, the patient showed

increased strength specifically with right hip musculature, although continued

demonstrated significant weakness in the right lower extremity. Many of the PREs that

were issued to strengthen the weak muscle groups were part of the home exercises, which

the patient reported he was not doing regularly, which would contribute to this observed

weaknesses. The patient exhibited minimal clinically important differences in balance as

shown by the BBS. Despite the significant improvements in this static balance score, the

patient was still at increased risk of falling with dynamic activities based on the DGI,

which more accurately describes his balance during gait. The 10 MWT regressed

compared to initial test. There are several potential explanations for this regression,

including that the test was performed later in the re-evaluation, so patient fatigue could

have been a factor, and the patient was tested without his AFO or assistive device, which

he had been accustomed to using on a regular basis outside of the clinic, which could

have decreased the patient’s confidence.

Several individual barriers were noted throughout this study. As discussed above,

the outcome measures and testing did not follow the same order from the evaluation

during the reassessment, thus possibly causing improvements on one test and declines in

the later tests when fatigue became a factor. It would have been ideal to use the Stroke

Impact Scale at evaluation and reassessment for subjective measure, however the trained

administers were not available to perform the test. Therefore, the only subjective

information was through informal discussions, in which the patient expressed concerns of

marginal progress being made with therapy, but wanted to continue working towards his

goals in therapy.

There were patient barriers that interfered with treatments throughout the course

of physical therapy. Firstly, with English being a secondary language, the patient

experienced difficulty with instruction comprehension, and required maximal tactile cues

and demonstration. Cognitive deficits from his stroke contributed to his difficulty of

understanding and following the interventions and sequencing, which was further

assessed with the speech therapists. The patient couldn’t afford a car and relied on the

public COTA bussing system as means of transportation, which often arrived late to

therapy sessions. Also, J.O.’s financial issues prohibited him from attaining refills for his

blood pressure prescriptions, which was discovered when his blood pressure was in

dangerous levels at the beginning of a session, and a non-emergent ambulance was

needed for patient to get appropriate treatment. Therapeutic progress was impeded in the

following therapy sessions secondary to attendance; J.O. was only able to attend 11 of the

45-minute treatment sessions scheduled on the course of 8 weeks, and a therapy session

that was ended early due to vitals exceeding appropriate limits. Additionally, minimal

home carryover in the HEP slowed the progress being made in therapy.

In hindsight, it may have been more beneficial for the patient to have more tasks

directly relating to gait, such as stepping over objects while ambulating and treadmill

training, and less focus on the stance progression at the stairs in order to maximize the

massed repetition of gait, which promotes neuroplasticity.6 Some task-oriented research

shows that there are minimal improvements in gait when the tasks performed are not

directly related to gait.40, 41 If it were available, a body weight supported treadmill may

have been beneficial as it is directly related to gait and involves maximal repetition.6 It

was expected that the patient would have been seen for 16 visits compared to the 11,

which may not have been long enough to promote the massed practice and repetition

required to evoke neuroplastic changes. Along the same idea, it would have been ideal to

have longer treatment sessions scheduled, as the patient often arrived late to his

appointments, several times having only 30 minutes of physical therapy. The patient

received physical therapy prior to occupational and speech therapy, thus when he arrived

late, it was not possible to extend time in therapy.

There is growing evidence that is showing improvements in functional tasks with

patients post stroke after the 6-month period; however, more research needs to be done as

to the interventions, timing, and amount of sessions in order to achieve these

improvements.50 Pleurala et al. recommend that an outpatient stroke patient be seen 3

times a week for 8 weeks in 45 minute treatment sessions in order to make gains past 6

months.42 Comparatively, this case study attempted to utilize 2 times a week for 8 weeks

with 45-minute treatment times; the patient only attended 1 time a week for 5 of the

weeks. It is unknown if there would be significant changes if the patient were to have

received therapy 3 times a week compared to the 1 to 2, or if there would have been any

additional changes if the patient were to have made all of his appointment sessions.

Although not possible, it would have been imperative that the patient received

early rehabilitation within the first three months of his stroke, were evidence shows most

neurologic recovery.31, 33, 41 In most of the evidence based rehabilitation studies agree there

is a significant benefit on functional outcomes and ADL status if the person receives

rehabilitation within the first 30 days.5, 43, 44, 46 Kelly-Hayes further describes functional

improvement if the patient receives at least 16 hours or more of physical therapy within

the first 6 months, with a minimum of 45 minutes per treatment session.5 Therefore, due

to this missed opportunity, the patient had developed many compensatory strategies and

habits over the 6 months, that proved difficult to overcome in rehab during this time

frame.

In the chronic stroke population, there is a lack of agreement on the best clinical

practice guidelines for stroke rehabilitation.5, 7, 21, 45, 49 This case study describes there may

be potential to increase significant changes with a combination of task-oriented and

neurodevelopmental approach in the functional status of a chronic stroke patient,

specifically balance and endurance, but more research is required in order to further

understand the potential for patients in this stage of recovery. Also, there is a strong need

to find optimal practice guidelines for stroke rehabilitation in regards to frequency,

intensity, time, and type of treatment in order for physical therapists to provide the best

treatment for their stroke patient population.

ANALYSIS OF FISCAL IMPACT

Medicare was the patient’s primary insurance. There were no previous therapy

visits in the year, thus the $1,880 cap was completely intact. The patient received

physical therapy, speech therapy, and occupational therapy. Medicare reimbursed the

physical therapy evaluation at a cost of $71.67; the re-evaluation was $39.67, and the

average treatment costing around $100 depending on the CPT code. The cost of a single

unit of therapeutic exercise was $29.62, a unit of neuromuscular re-education cost

$30.88, and therapeutic activity cost $32.44. The sessions were around 45 minutes, which

equates to three units, on the span of 8 weeks. The total amounted to approximately

$1,000 for total physical therapy visits, in which the patient was not responsible for any

of these therapy costs, as he did not exceed the hard cap on Medicare.

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