Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Taylor Cocuzza
EXSC 555-004
The first principle, “Use It Or Lose It” focuses on the fundamental concept that if a
patient does not use the affected limb(s) or behaviors, they will eventually develop a learned
non-use for that limb. In result, neural efficacy will decline for those specific brain connections
as well as muscular atrophy, which could potentially lead to difficulty or inability for restoration of
function. The second principle, “Use It and Improve It” holds similar values as “Use it or Lose
It.” It refers to the ability to restore or improve functional deficits caused by the neurological
injury on the basis of activating the specific brain functions that were impacted. Therefore, by
using what was affected, a patient can not only prevent complete loss of function, but improve
functional ability as well. The implementation of these principles is quite straightforward. The
therapist will develop a treatment plan that requires the patient to use the limb(s) affected by
neurological injury. This could also be applied to any other impairment such as dysarthria,
aphasia, ataxia, dysphagia, spatial neglect, etc. Therefore, this patient will be required to use his
right arm and hand, whether actively or passively, during therapy and in everyday application
outside of the clinic and overtime, improve function. Some techniques could be applied which
include the Constraint Induced Movement Therapy (CIMT), which involves restricting the non-
affected limb for extended periods of time. I am able to address these principles by applying
this type of treatment because if a patient is required to progressively use the affected limb, they
increase the usage of that limb and the potential of improving overall function of what was
affected by increasing sensory and motor representations in the cortex. This can also prevent
him from adapting and using his left-hand to complete his everyday routines.
Although using the limb is beneficial, it is important to focus on performing therapy that is
specifically aimed to that patient’s deficits and goals by applying the third principle, “Specificity
Matters.” Similar to muscles, you can’t improve the neural plasticity of a specific brain region
unless you actually engage that particular region. The implementation of this principle would
be directed with the idea that every patient is different and the Plan Of Care should concentrate
on regaining skills that would allow our patient to return to work and perform daily tasks as a
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father and husband. Our patient has moderate difficulty both grasping objects with his right hand
as well as holding his right arm up against gravity. He has mild aphasia and loss of sensation of
the right upper extremity. Being a plumber, it is important to regain overall strength and grip
strength in his dominant hand. Catering to the first two impairments could be implemented by
applying exercises that work to improve strength and range of motion. These strengthening
exercises would require using the right arm to actively or passively, with or without Electrical
Stimulation (ESTIM), to perform exercises that activate muscles within the shoulder girdle and
upper extremity. One would also apply pinch and grip strengthening, upper extremity weight
bearing, and cognitive-speech exercises into treatment. The strengthening and weight-bearing
exercises will address this principle because it will improve functional connectivity for regions
that affect his ability to hold his arm up against gravity as well as gripping objects. Exercise with
a combination of manual therapy, ultrasound, and E-STIM can also improve loss of sensation in
that limb as well. To engage the networks and produce a result within the brain that affect his
aphasia, one could address this and either having him attend speech therapy, or apply this
concept in combination with exercise. With mild aphasia, it is common that the patient has
implementation could be an exercise where the patient is seated and must reach with one arm
in various planes to grab a clothespin with instruction to pin it overhead to a rim all while weight-
bearing on the other upper extremity; the clothespin will have a letter or color on it or and you
can ask the patient to identify a word that starts with that letter or one that rhymes with that
color. This will address the principle because it requires engaging multiple body parts and
pathways that were impacted by the stroke. The particular exercises and extent of using E-
STIM, passive ROM, particular activities are dependent on the patient’s current capabilities and
Matters”—tend to go hand-in-hand with treatment. Duration implies that gains in neural plasticity
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are retained and improved if the skills are practiced over an extended period of time. Repetition
on the other hand claims that neural plasticity is improved when the exercises or tasks
performed within one treatment session require high repetitions. Our patient is approved for 5
hours each week for a total of 12 weeks. We’d implement duration by having therapy cycle
between 4-5 days every other week. If the week involves 4 sessions, 3 of those days will include
one hour of therapeutic exercise, while the last day will combine one hour of exercise with an
hour of manual therapy and assessments (on every 8th visit). The next week will involve 5, one-
hour visits and focus primarily on exercises and tasks. For every exercise performed, they will
consist of high repetitions of 30 and over and number of sets dependent on clinical judgment.
The repetitions, resistance, or difficulty will increase progressively. We will implement both
within the Home Exercise Programs (HEP) that will be given and demonstrated to the patient
and caregiver. If we implement CMIT, we will give specific instructions on the expectation of
how long the patient will wear the restrictive device: 70% of awake hours. I find it important to
inform the caregiver of allowing independence at home. Intensity of the exercises both at home
and in the clinic will increase throughout the 12-week period. Consistency is the key when it
comes to rehabilitation for stroke patients and these principles will be addressed by allocating
at least one hour sessions of time multiple days a week in addition to including high-repetition
The sixth principle, “Timing Matters,” refers to the various timeframes post-stroke that
different aspects of neural plasticity occur. There is a time period shortly after the stroke in
which a patient will see large learning curves and increases in neuroplasticity of those affected
regions are engaged. Therefore, I would implement treatment early on with this patient to
ensure the patient can achieve as many gains in functional ability as early as possible.
Addressing this principle, I will change the demands and task levels according to where they
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The seventh principle, “Motivation Matters” explains that what a patient gets out of
therapy and how important treatment is viewed can largely affect the impact rehabilitation has.
It’s important to know the mental and emotional state of the patient prior to treatment as well as
what is important to them when implementing this principle. Communicating with the patient is
also very important within this principle whether it be explaining why we are performing a certain
exercise, giving encouragement, or just listening to his concerns. The tasks will be tailored to his
goals of returning to work as a plumber and performing everyday activities with his wife and
children. These techniques address this principle because they focus on keeping the patient in
the right mindset so as the patient improves, I can apply functional tasks that make his goals
The “Age” of the patient makes the eighth principle of neuroplasticity. Our patient’s age
matters because neural plasticity tends to have a larger potential in younger patients than in
older ones. With our patient being 45 years old, it is important that implementation of treatment
is modified for someone his age. Therefore, it is crucial to know if the patient has any other
comorbid diseases to ensure exercises are not too strenuous on his joints, heart, lungs, etc. In
addition, one must be aware that progress may take a little longer than if I were to treat a
younger patient. This will address this principle because we are catering our treatment to
potential limitations and lagging someone his age may have preventing discouragement and/or
injury.
The ninth principle, “Transference” is also considered when dealing with patients of
neurological injury. “Transference” refers to the beneficial impact that one practiced skill or task
may have on improving the ability to perform similar ones. I would implement this by applying
exercises to complex tasks, complex environments, and adding disassociation into treatment to
help transfer to real-life settings. For example the fine motor and pinch-grip strengthening
exercises will be designed with the idea that he is a plumber and we want to benefit other
muscles and ROM within the hand. We will have him not only perform generic exercises with
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tools such as the Digiflex or Handmaster, but also having him practice unscrewing nuts and
bolts, reeling against or with gravity eliminated, and radio-unlar deviation with the Flexbar. We
can also challenge him by requiring him to hold a weighted ball at 90° shoulder flexion and
perform mini-oscillations and as well perturbations. Giving him exercises where he holds a
weighted dowel and supinates-pronates his arm can help him use a wrench again because it
involves a similar motion as well as incorporating grip strength. Using the rebounder with a
weighted ball can help him gain strength and coordination of his upper limbs as well as transfer
into playing catch with his children again. We can also apply functional electrical stimulation in
the beginning of treatment to attempt to restore that mind-body connection while performing
specific tasks with his affected limb. Many everyday tasks both in his line of work and his
household require the ability of disassociation between both upper extremities. Therefore,
having him use the Upper Body Ergometer, radioulnar deviation, and reeling will force him to
perform contradicting movements with both arms at the same time. Strengthening exercises will
not only enhance his ability to keep his arm up against gravity for prolonged periods of time, but
increase the load in which his affected arm can handle against gravity. These exercises
address this principle because the treatment will be applied in a sense that can be generalized
to the real world and will work toward him gaining independence at work and at home.
The tenth principle, Interference is also significant to keep in mind because while some
tasks enhance the patient’s ability to use those skills across various tasks, other exercises can
interfere with progress or reacquiring of other abilities. This would be if we only implemented
associative tasks to make it easier on our patient or gave too much feedback for every task. Our
patient may begin to develop bad habits to compensate for their deficit in ability. It is important
to address and correct these habits in therapy as well as make sure his functional assessment
scores are not reflecting his ability to perform these tasks in result of the adaptation, but rather
indication that his affected limb is improving. Our tasks will vary and we will try to keep the
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training environment similar to one he experiences when he performs those tasks. In addition,
we will require him to practice these tasks before applying electrical stimulation to prevent a
reduction in functional organization. By doing these things, we are addressing this principle by
forcing him to unlearn those compensatory techniques and require him to actively engage both