1. Implementing an Evidence-Based HEP to Improve UE Function in a Patient 26 Years Post-Stroke
Chanel Cohen, SPT, ATC; Jennifer Escobido, SPT; Anna Gray, SPT; Nicole Milad, SPT;
Francesca Romeo, SPT; Danielle Trias, SPT
Research Advisor: Laura Z Gras,PT,DPT,DSc,GCS
ABSTRACT
Introduction: Physical therapy is essential to recovery following a cerebrovascular accident (CVA). The
opportunity for neuroplasticity is initially strong following an injury to the brain; however, there is a
lack of evidence to support the degree of neuroplasticity in chronic cases. The purpose of this study
was to assess the degree to which neuroplasticity can occur in a patient 26 years post-stroke through
the combined effects of mental imagery, constraint-induced movement therapy (CIMT), mirror
therapy, and proximal scapular strengthening.
Method: This case report followed a 33 year old male 26 years post left middle cerebral artery CVA
following the resection of a large oligodendroglioma from the left temporal lobe. We utilized the
Canadian Occupational Performance Measure (COPM) to help develop a 16 week, patient-centered
home exercise program (HEP) incorporating mental imagery, mirror therapy, CIMT, and proximal
scapular strengthening. Exercises were performed for 2 hours each day, 3 days per week. Progress was
measured using impairments measures, the Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Action
Research Arm Test (ARAT), COPM, and Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST).
To measure change from pretest to posttest, MCID and MDC from the literature were utilized. Weekly
check-ins via email were used to discuss exercise progression.
Results: Improvements were seen in right gross upper extremity strength and scapular stabilization,
right scapular positioning, and the motor portion of the FMA-UE. Our patient demonstrated
improvement in the motor portion of FMA-UE from 35/66 to 42/66, exceeding the MDC of 5.2.
Subjective improvements in performance and satisfaction were noted on the COPM.
Discussion: This is the first research of its kind due to the chronicity of our patient’s condition. To our
knowledge, there are no publications that study the effects of interventions on patients with chronic
stroke beyond 10 years. Our patient’s improvements are clinically significant, and he reported greater
satisfaction with the execution, function, and stability of upper extremity movement. Our results
provide insight into the effects of combining commonly used neurological interventions that promote
neuroplasticity and functional improvement. We achieved this by creating a flexible, patient centered
program based on current evidence that utilized our patient’s self-awareness of his perceived
limitations. To enhance that applicability to a larger patient population, further research is necessary.
Conclusion: This study could provide insight into the efficacy of continued skilled physical therapy to
induce neuroplastic changes in patients with chronic stroke. A 16 week home exercise program
combined the effects of mental imagery, CIMT, and proximal scapular strengthening, and resulted in
meaningful improvements in upper extremity motor and function. While more research needs to be
completed, this study can be used to contribute to our understanding of neuroplasticity in the chronic
state.