The Power of Rehabilitation: Key Factors

These people don't understand survivor recovery one bit!

The Power of Rehabilitation: Key Factors

(Note:  In this guest blog from Chris Persel, Director of Clinical Services and Director of Behavior Programming for CNS, he discusses CNS’ Rehabilitation Super Power: Intensity, Repetition, Consistency and Integrity).

Individuals that have experienced a neurological injury from a traumatic event, stroke or other mechanism require specialized, skilled rehabilitation to maximize recovery. Research and clinical experience informs us that receiving treatment as soon as possible and at the appropriate level is essential. However, funding resources and support for treatment can be extremely limited, making every minute available for rehabilitation valuable. The treatment program and therapeutic staff have a responsibility to make their impact meaningful and effective(YES, LIKE EXACT 100% RECOVERY PROTOCOLS, which they don't have!). Several elements are important to maximize this rehabilitation opportunity, including establishing enriched, demanding environments, capitalizing on principles of neuroplasticity, providing treatment intensity and maintaining consistent program integrity.

ENRICHED ENVIRONMENT

Enriched, demanding environments create a strong foundation for success. The treatment environment must be challenging and create a demand for the patient to respond. Patients require engagement in activities that present choices which elicit a response, empowers them to make decisions and compels them to demonstrate skills, rather than have others do things for them. Studies support positive outcomes from enriched environments, such as increased adult hippocampal neurogenesis, improved spatial learning ability¹, and increased activity levels². One review indicated that work tasks that stimulate verbal intelligence and executive functions helped sustain good cognitive functioning³, so treatment environments that provide that experience are essential.

User engagement/motivation is simple.

You don't understand ONE GODDAMN THING ABOUT SURVIVOR MOTIVATION, DO YOU? You create EXACT 100% recovery protocols and your survivor will be motivated to do the millions of reps needed because they are looking forward to 100% recovery. GET THERE!

 

NEUROPLASITICITY

A few key principles of neuroplasticity can guide rehabilitation treatment. “Use it or Lose it” indicates that neural circuits that are not actively engaged in task performance for an extended period of time begin to degrade. This means that experiences after brain injury, such as an active skill rehabilitation program, can protect neuronal circuitry that may otherwise be lost. “Use it and Improve it” outlines that treatment that drives specific brain function and performance will lead to enhancement of that function. For example: “Forcing” engagement in tasks using an impaired limb can lead to enhanced functioning in that limb (e.g. constraint-induced movement therapy). “Repetition Matters” stipulates that induction of neuroplasticity requires sufficient repetition of activities(But you don't give patients the EXACT NUMBER OF REPETITIONS, DO YOU? So you are a failure as a therapist?). This concept demonstrates the strength of residential rehabilitation treatment programs because they allow for performing increased repetitions of specific tasks in the exact setting where these skills need to be utilized. In fact, research supports the observation that neuroplastic change and functional improvement occur when large numbers of a specific task are performed, however, this change does not occur with fewer repetitions. Unfortunately, a large multicenter study found that over half of the upper limb and gait training rehabilitation sessions did not come close to meeting the number of repetitions needed to impact patient neuroplasticity. Thus, one item of focus for rehabilitation professionals should be the number of repetitions and the type of activity performed.

INTENSITY

For programs to optimize patient recovery, sufficient learning and treatment intensity is key to the induction of neuroplasticity. If clinical therapy combined with residential rehabilitation can provide “treatment” for up to 16 hours each day, seven days a week in a structured setting, they will have provided 480+ hours over a month’s time. Studies found that this level of intense therapy over a short amount of time can improve outcomes for stroke patients with aphasia⁴ and decrease risk of hospital readmission for all rehabilitation patients⁵. Intensive neurorehabilitation treatment in a rehabilitation facility, that encompasses at least 20 therapy hours per week, promotes the greatest functional recovery⁶ and there is no evidence of a ceiling effect of therapeutic intensity beyond which no further response is observed⁷.

INTEGRITY

For rehabilitation programs to maximize their impact, treatment must also be delivered with consistency and integrity. What is program integrity? It is consistently implementing an intervention/program as intended. This allows skills to be mastered more quickly and produces the most effective and efficient strategies for recovery. Why is this important? It reduces “wasting time, money, resources” while maximizing the hope and energy of all involved. Lack of treatment integrity can diminish the field as a whole which could erode future resources. Following consistent treatment pathways improves efficiency, reduces the conclusion that there is “No Progress” and better informs staff on when to adjust programs.

The power of rehabilitation success after neurological injury lies in the consistent application of intense, targeted interventions as a part of an enriched and challenging treatment environment.

• Xiong Y, Mahmood A, Chopp M., Emerging treatments for traumatic brain injury. Expert Opin Emerg Drugs. 2009 Mar;14(1):67-84.
• Janssen, H., Ada, L., Bernhardt, J., McElduff, P., Pollack, M., Nilsson, M., and Spratt, N.J., Disability Rehabilitation, Early Online: 1–8, 2013 Informa UK Ltd.
• Then, F.S., Luck, T., Luppam M., König, H., Angermeyer, M.C., Riedel-Heller, S.G., Differential effects of enriched environment at work on cognitive decline in old age. Neurology May 2015, 84 (21) 2169-76.
• Bhogal SK, Teasell R, Speechley M. Intensity of aphasia therapy, impact on recovery. Stroke. 2003 Apr;34(4):987-93.
• Andrews AW, Li D, Freburger JK., Association of Rehabilitation Intensity for Stroke and Risk of Hospital Readmission. Physical Therapy 2015;95: 1660-7.
• Königs, M., Beurskens, E.A., Snoep, L., Scherder, E.J., Oosterlaan, J., Effects of Timing and Intensity of Neurorehabilitation on Functional Outcome After Traumatic Brain Injury: A Systematic Review and Meta-Analysis, Archives of Physical Medicine and Rehabilitation, Volume 99, Issue 6, 2018, Pages 1149-1159.
• Shiel, A., Henry, D., Clark, J., Burnett, M.E. and McLellan, D.L., The effects of increased rehabilitation therapy after brain injury: results of a prospective controlled trial. Clinical Rehabilitation 2001; 15: 501–514