Stroke is debilitating. For those who suffer with the effects of a stroke, and those who have loved ones who have suffered from stroke, rehabilitation is a physically demanding and time-consuming process. Find out how new research is helping therapists work with stroke patients to regain their functions. 

According to Stephanie Combs, PT, MS, NCS, a faculty member at the University of Indianapolis, an assistant professor in UIndy’s Krannert School of Physical Therapy, and a board-certified clinical specialist in neurologic physical therapy, “Many individuals who survive stroke are left with physical and cognitive deficits impacting their ability to remain functional within the community.”

Typically, she says, rehabilitation for individuals post-stroke consists of low-intensity interventions, provided during the acute and sub-acute phases, rarely continuing past one year.

However, a growing body of evidence indicates that recovery can take place after the one-year mark – specifically, when it is provided through high-intensity and task-specific therapeutic interventions, says Combs.

A barrier for individuals with chronic disability is having a limited access to the right therapy services. Often, this is because reimbursement for physical therapy and occupational is limited, she says.

A Feasible Approach

“According to the American Stroke Association, stroke is the leading cause of disability in the United States,” says Combs. Which means stroke remains a basis of concern for therapists and disabled patients. She says, “therefore, it is important that physical and occupational therapist[s], clinicians, and researchers find alternative ways to assist patients with long-term disability, [and find ways] to maintain – and even improve – function in their home and communities.”

Combs and her collaborators have been working on a couple of research projects involving chronic stroke patients. In one, they have been putting chronic patients through an eight-week, 24-session training regimen, using a body-weight support treadmill and 3-D analysis for testing and evaluation of patient performance in hopes of determining whether the training improves the patient’s gait.

Stroke Camp

In conjunction with University of Indianapolis School of Occupational Therapy, Combs Stephanie Kelly, PT, MS, and Rebecca Barton, DHS, OTR, have been participating in a study project informally called “stroke camp”. In the project, chronic patients underwent a program involving intensive, task-specific therapy for two weeks, a few hours each day, and were tested for activity and motor skill improvements.

Researchers are currently analyzing the data. Combs says, for instance, “We have developed a two-week intensive rehabilitation program for individuals with chronic stroke that dually serves as an educational experience for physical therapy and occupational therapy students,” says Combs.

The interventions combined traditional and emerging concepts in neurorehabilitation, in which patients practiced activities that were meaningful to them in order to encourage them to work toward achieving their functional goals. The opportunity allowed students to apply intervention concepts within a collaborative interdisciplinary setting.

Combs says, “We are currently investigating changes in motor, activity, and participation outcomes in persons with chronic deficits due to stroke following the intensive, task-specific rehabilitation program. We are hopeful that this ‘booster-type’ intervention will provide further evidence for the importance of continued emphasis on life-long rehabilitation for individuals with stroke and will provide a feasible alternative to current neurorehabilitaton services.”
 
People can have a stroke at any age, says Combs.  For this project, she says the participants spanned from ages 45 to 78. “We actually recruited for persons with stroke between the ages of 18 to 80, which is typical for many studies conducted with patients with stroke, but it seems that most of the people available for our program were middle- to older ages,” says Combs.

A ‘Boost’ in Treatment
 
One innovation in stroke therapy employed at Combs’ facility is “booster” treatment, which is an intervention delivered in a short burst of duration with a high frequency of treatments. She says “our intense rehabilitation program was provided three hours daily for two weeks.”

“The interventions provided were standardized for all participants, but participants were able to gear the treatments toward activities that were meaningful to them in assisting them to meet their functional goals,” says Combs.

“Patients with chronic stroke often do not have access to rehabilitation services, so we are proposing that interventions provided in a booster-like format may prevent decline of function and/or secondary complications due to difficulty maintaining functions gained in the acute stage after stroke.”

Combs admits that speech-related problems were not addressed in this program, because physical and occupational therapy students and faculty focused on the intervention process. However, she says that the team believes the booster-type of program may be an efficient means of providing care. Stephanie Kelly, PT, MS, one of Combs’ collaborators, concurs.

Kelly says that although speech and stroke rehab were not part of their study, other studies have facilitated a similar model with speech. For instance, says Kelly, “If you Googled ‘Speech stroke constraint induced’, you will find several references for program[s] that use a booster-type model for rehabilitation of aphasia.”

Aphasia in Stroke Patients

More than 1 million Americans have developed aphasia – more than the number of people who have been diagnosed with cerebral palsy, multiple sclerosis, Parkinson’s disease or muscular dystrophy. Approximately 20 percent of the 600,000 Americans who suffer a stroke each year will develop aphasia, says Wendy Silverman, MS, CCC-SLP, clinic director at the Hempstead, N.Y.-based Hofstra University’s Speech-Language Hearing Clinic.

As a language-processing disorder, aphasia impairs a person’s ability to speak or understand speech. “Aphasia manifests itself differently in different people, but generally the individual’s intelligence is intact. Nevertheless, they may not be able to read a utility shut-off notice, ask waiters for a cup of coffee, or follow a news story on TV,” says Silverman.

The onset is sudden – in an instant, one’s life is irrevocably altered, and the effects are generally long-term, says Silverman. “Because of the disconnect between their ability to think and their inability to communicate, people with aphasia often become extremely frustrated, depressed, and isolated.”

Physical Therapy for Speech

William F. Katz, PhD, has started using a rare machine called an electromagnetic articulograph (EMA) to treat stroke victims. This machine is one of only about 40 in the world which tracks patients’ speech movements and shows them how to position their tongues to create speech sounds. Katz calls it “physical therapy for speech.”

Katz’s experience with stroke rehabilitation is quite extensive. He has worked with patients with Broca’s aphasia, as well as apraxia of speech, and he has diagnosed and treated patients with foreign accent syndrome – a very rare disorder. Also, a professor of communication disorders at the University of Texas at Dallas (UTD) School of Behavioral and Brain Sciences, he teaches courses in aphasiology, phonology, and speech science and phonetics.

Katz has been conducting research and clinical treatment with stroke patients at the Dallas-based Callier Center for Communications Disorders. Katz has been doing research and clinical treatment with stroke patients. (Additional information is provided in the sidebar titled “A New Tool for Speech Therapists?”)

In his research, Katz has discovered much about the speech patterns in stroke patients. For instance, to say the word “slant,” the tongue must touch a bit behind the teeth. When uttering the word “boot,” the mouth must be pursed. Although automatic to most people, speech is a complex process of tongue, mouth, and jaw, a combination of body parts known as the articulatory organs, which, because they are inside the mouth, are difficult to observe in action.

Currently, Katz has been employing visual biofeedback treatment for people suffering from apraxia of speech. These stroke victims have no ability to produce words. They have to relearn how to use their combined speech organs – mouth, tongue, and jaw.

As he explains, it can take one year of therapy to get these people to learn how to say a few vowels again. This is painstakingly, tedious therapy. Therefore, he says, EMA is a promising tool because of its visual biofeedback.

“In the past, scientists used candle soot to mark the placement of these organs in making words,” says Katz. The UT Dallas Callier Center has two of these advanced machines. Wearing a metal halo over their heads, the patients sit in front of a computer screen. Small sensors attached to thin wires are placed inside their mouth.

As they struggle to form a word, a magnified image of their mouth movements appears on the screen before them. The EMA machine helps patients with motor learning by showing them how to position their tongue to create speech sounds – a visual biofeedback process that Katz calls “physical therapy for speech.”

Most of the people who Katz sees at the Callier Center suffer from apraxia of speech, a disorder marked by an inability to perform voluntary movements of the articulatory organs, which are necessary to produce spoken language.

So, even though patients understand language, some stroke survivors are completely unable to produce any words or may use the wrong words, instead. Katz says, “it takes a lot of time to fix broken speech, but [the EMA] machine is giving us an important new tool.”

— Haley K. Jestice is a staff writer for Therapy Times. All questions and comments can be directed to hjestice@therapytimes.com