Action research in rehabilitation with chronic stroke recovery: A case report with a focus on neural plasticity

Abstract

BACKGROUND: Chronic stroke patients are primarily referred to general rehabilitation, rather than to specific neurorehabilitation. Currently, there are no Danish clinical guidelines for chronic stroke, but recent research in neuroplasticity has contributed to possible rehabilitation interventions for these patients.

OBJECTIVE: The purpose of this project is to describe the use of a specialized neuroplastic approach in combination with an already existing training program.

METHODS: The project is designed as an action research project concerning four participants with chronic stroke. Through ten intervention, a neuroplastic focus has been added to their group training program including daily home training. Participants were tested before and after the intervention with MAS, DGI, 6MWT, SSQLS.

RESULTS: All four participants improved their functional levels and their quality of life following the intervention.

CONCLUSIONS: This report indicates that a specific neuroplastic focus in combination with action research has an impact on the participants with chronic stroke. However, there is still no clarity regarding what type of rehabilitation methods can be considered the most efficacious in promoting neuroplasticity. This case report serves as a pilot project for further studies of how to implement neuroplasticity in physical therapy.

Keywords

Neuroplasticity chronic stroke action research physiotherapy case report

1 Background

Maintenance care for persons with stroke in the chronic phase constitutes a considerable burden within neurorehabilitation (Terent et al., 1994; Kaste, Fogelholm, & Sama, 1998). In Denmark, stroke is the leading cause of adult disability with an estimated 30-40,000 persons living with long-term sequelae after stroke (Jørgensen, Holmestad-Bechman, Celinder, & Tronier, 2013). This underpins the relevance of investigating efficacious rehabilitation methods for stroke in the chronic phase. The Danish Health Technology Assessment (HTA) concludes that chronic phase stroke rehabilitation is likely to have not only a clinical effect, but also an economic one by improving chances of returning to work and reducing dependence on public services, such as early retirement and home care (Sundhedsstyrelsen, 2011).

Within this context, the concept of neuroplasticity has heralded new possibilities for innovative interventions, e.g. in the physiotherapeutic neurorehabilitation.

Among the challenges, facing current neuroscience are the description of the underlying mecha-nisms of neuroplasticity, the relationship between plasticity and behavior, and the advancement of plasticity in education and clinical rehabilitation (Lundbye-Jensen, 2010).

Neuroplasticity can be defined as the ability of the nervous system to respond to intrinsic and extrinsic stimuli and thus adapt morphologically and functionally (Mogensen, 2013; Lundbye-Jensen, & Nielsen, 2011). In accordance with this definition, activities and experience form the basis for lifelong modulation of neural activity and reorganization of neural networks that influence memory, characteristics and behavior (Cramer, 2011). This insight offers new hope to chronic stroke patients, whose symptoms can be defined as having persisted for more than one year after the onset of the disease, and whose sequelae are sufficiently severe to merit long-term rehabilitation (Sundhedsstyrelsen, 2005, 2011). One of the challenging aspects of rehabilitation is the huge variance in individual response to treatment due to the underlying heterogeneity in motor recovery owing to individual spontaneous recovery and learning patterns (Takeuchi, & Shun-ichi, 2013). The consequence of the brain’s capacity for change is a potential for regeneration and improvement that provides the means for lifelong learning (Fredens,2012).

Several international studies have stressed the need for an improved and more evidence based approach specifically designed to address chronic stroke (Christensen, Overgaard, & Rasmussen, 2013). The way we approach rehabilitation requires rethinking, as evidenced by the latest Danish national clinical guidelines for adults with acquired brain injury that advocate an individual integration of approaches in a cyclical rehabilitation process (Sundhedsstyrelsen, 2014). Moreover, the Dutch national guidelines recommend types of rehabilitation that incorporate aspects that are conducive to positive neuroplasticity (Hubbard, Parssons, Nielson, & Carey, 2009; Royal Dutch Society for Physical Therapy, 2014).

Physical therapy as a profession needs to become engaged in how neuroplasticity vis-á-vis chronic stroke can translate into physiotherapeutic practice, and how the knowledge base can be implemented in other diagnoses (Gade, & Nielsen, 2011). Recent neuroplasticity research has paved the way for novel approaches and interventions that hold potential for promoting neuroplasticity.

High intensity repetitive task oriented training appears to be the most efficacious principle in pursuing motor recovery after stroke, regardless of chronicity (Hubbard, Parssons, Nielson, & Carey, 2009; Royal Dutch Society for Physical Therapy, 2014; Langhorne, Coupar, & Pollock, 2009). Recent studies are unveiling that the potential for achieving changes in motor learning through task oriented training is superior to conventional rehabilitation (Takeuchi, & Shun-ichi, 2013). Recommendations regarding the exact number of repetitions and duration are still lacking. Animal studies, however, have demonstrated that recovery after impaired upper extremity (UE) function following stroke requires 400–600 repetitions per day (Lang, 2009). Similarly, improving gait requires 1,000–2,000 steps within a time span of 30 minutes per day (Lang, 2009). Multiple repetitions cannot produce adaptive plastic changes in the motor cortex without simultaneous learning (Plautz, Milliken, & Nudo, 2000).

There is evidence that adaptive plastic changes will continue to take place in the motor cortex as long as a given task is made progressively more difficult and remains challenging (Nielsen, 2015; Lundbye-Jensen, 2010). Similarly, animal studies have demonstrated that problem-solving tasks at higher levels of complexity elicit greater activity in the cerebral cortex than simpler tasks (Plautz, Milliken, & Nudo, 2000; Bennett, Edward, & Rosenzweig & (1995; Remple, Bruneau, VandenBerg, Goetzen, & Klein, 2001). Additionally, to progress the level of difficulty of a task, neurophysiological theories of motor control and learning often recommend dual-task paradigms that can engage and augment cognitive faculties, e.g. by challenging the ability to divide one’s attention – a faculty that is often affected in stroke patients (østergaard, 2010, Shumway-Cook, Wollacott, 2012).

Active participation appears to promote learning outcome, thus contributing to neuroplastic change (Royal Dutch Society for Physical Therapy, 2014; Perez, Lundbye-Jensen, & Nielsen, 2006). Moreover, in animal studies, a relationship can be found between attention and motor neuron activity, and therefore it is conceivable that focused attention may contribute to a synchronized firing of neurons (Schmied, 2000).

Studies of stroke patients show that patient-centered goal setting can increase motivation and involvement in rehabilitation, thus resulting in better outcome (Takeuchi, & Shun-ichi, 2013). Improved information to patients and relatives may also have a positive impact on patients’ motivation and expectations for their rehabilitation (Johansson, 2011). There is evidence that for the training to be deemed motivating, the patient must find the exercises meaningful and be able to see the purpose of them (Takeuchi, & Shun-ichi, 2013; Hubbard, Parssons, Nielson, & Carey, 2009). When comparing conventional rehabilitation to goal-oriented, task-specific training, it appears that the latter is associated with long-term motor learning and concomitant cortical reorganization (Takeuchi, & Shun-ichi, 2013).

It has been found that immediate reward provides optimal learning outcome by building up an expectation that successful repetition of the task in question will maximize the chances of being rewarded again (Gurney, & Redgrave, 2006; Nielsen, 2015). In many ways, feedback is akin to reward, since both generate dopamine secretion in the brain (Lundbye-Jensen, & Nielsen, 2011). Lengthy explanations about details and quality of movement are not necessarily the optimal solution: Simple, unambiguous and easily interpreted feedback is often preferable, since it targets areas of the brain that have neither language nor comprehension thereof (Lundbye-Jensen, 2010; Lundbye-Jensen, & Nielsen, 2011). Evidence does however suggest that positive feedback and reward, in spite of their beneficial effect, should be reduced over time in order to avoid dependence (Hubbard, Parssons, Nielson, & Carey, 2009; Maring, 2011).

The time immediately after training is almost as important as the training itself, for it takes time to store what has been learnt, and it is during this period that the brain is particularly susceptible to consolidation and vulnerable to interference (Lundbye-Jensen, 2010; Nielsen, 2015; Brashers-Krug, Shadmehr, & Bizzi, 1996). Studies show that exposure of the brain to unpleasant experiences, such as anxiety and lack of love or recognition can have a detrimental impact on the acquisition of what was intended to be learned (Larsen, 2011).

In one study, a short rest in the middle of the day (from six minutes to one hour) demonstrated a significant improvement in learning ability and performance. Accordingly, it may be helpful to rest after training (Lahl, Wispel, Willigens, & Pietrowsky, 2008). However, better results can be seen after a full night’s sleep of eight hours, since consolidation processes probably take place during sleep (Diekelmann, & Born, 2010). Consolidation has been shown to have a direct effect on synaptic plasticity, since sleep-related memory facilitates various forms of perception, motor learning, and complex cognitive tasks (Lahl, Wispel, Willigens, & Pietrowsky, 2008).

Dietary restriction may have an effect both on brain function and on the brain’s vulnerability to trauma and diseases (Mattson, Duan, & Guo, 2003). Experiments with mice and rats with stroke have shown that dietary restriction has a neuroprotective effect as well as a stimulating effect on the production of new neurons and synaptic plasticity (Mattson, Duan, & Guo, 2003). Caloric restriction appears to have a positive effect on brain plasticity by boosting synaptic resilience to metabolic and oxidative damage (Murphy, Dias, & Thuret, 2014).

Music can engender plastic changes in the brain through cognitive, emotional and motor processes (Johansson, 2011; Särkämö, & Soto, 2012; Tsai, Chen, Huang, & Lin, 2013). Music stimulates virtually the entire cerebral cortex, and thus, in persons who have suffered stroke, areas adjacent to the cerebral lesion will also be stimulated and thereby contribute to adaptive plastic changes (Särkämö, Soto, 2012). Electrophysiological studies have shown that music recruits the same neural networks that are associated with positive emotional experiences, and recent evidence in stroke patients has demonstrated that music on a daily basis can be beneficial to rehabilitation and can facilitate cognitive faculties, particularly attention (Johansson, 2011; Tsai, Chen, Huang, & Lin, 2013). Moreover, listening to rhythmic music stimulates and provides motor feedback, due to the activation of the motor and premotor cortex (Johansson, 2011). This may result in improved gait as well as arm and finger function (Johansson, 2011).

In neurologically impaired individuals, meditation has been seen to promote improved cognition and sustained attention while at the same time having a soothing emotional effect (Orenstein, Basilakos, & Marshall, 2011). Meditation and mental imagery, for example of a limb, may possibly produce an activation in the brain without any active movement of the limb in question, and this activation can facilitate new sprouting of neural networks, thus linking motor and functional rehabilitation (Arya, Pandian, Verma, Gang, 2011). By imagining a given movement, centers that initiate the task and carry out the movement are activated (Johansson, 2011). This activation takes place irrespectively of the level of physical functioning (Johansson, 2011).

Finally, evidence and potential for further development can be found for a number of other treatment methods such as Constraint-Induced Movement Therapy (CIMT), Bilateral Arm Training (BAT), electrical brain stimulation (for instance TMS and DCS), mirror therapy (Johansson, 2011), Virtual Reality (VR), and Robot Assisted Training (Sylvan, & Kesselring, 2012).

With the latest Danish national clinical guidelines as a point of reference, a cyclical rehabilitation process can benefit from incorporation of the above-mentioned types of intervention and treatment methodology. With a greater focus on learning processes and involvement of cognitive aspects, positive neuroplasticity can be supported, thus steering rehabilitation in a holistic rather than a function-oriented direction.

The current study describes the use of a specialized neuroplastic approach in combination with an already existing training program for four chronic stroke patients.

2 Material and methods

2.1 Design

This study is designed as a multi-case study, based on four cases that are followed longitudinally over a shorter period. The structure can be viewed as an ABA treatment plan with testing, treatment, and testing (Portney, & Watkins, 2009). Implicitly, the methodology requires that each case serve as its own control. The intervention is designed as action research, providing a unique opportunity to develop the basic concepts of neuroplasticity. Action research is characterized by being instructive, problem-oriented, content-specific, prospective, intervening in relation to change, improvement-oriented, participatory and cyclically process-oriented (Kildedal, Laursen, Duus, & Husted, 2012). A primary purpose of action research is to produce practical knowledge that is useful for people in their everyday lives (Reason, & Bradbury, 2001). This case study brings together several types of data collection in order to obtain detailed information about the phenomenon. The phenomenon is investigated from several angles and data are analyzed for convergence through simple descriptive comparison and subjectively perceived experience. To strengthen the argument, quantitative, and therefore realistic, perspectives are used employing tests and questionnaires, as well as qualitative perspectives, such as collation of experiences and participatory observations.

In a collaboration between clinicians, participants and researchers, theoretical generalization and logical analysis have been utilized and translated, based on the participants’ own level of understanding. The phenomenon has been studied in its natural context and environment. The design has been flexible and founded on action research, conforming to the professional aspects considered conducive to neuroplasticity. The process has been circular and has comprised repeated observations, reflections and actions.

Baseline measurements using four tests (phase A1) were carried out during the first week of the project, preceding by an intervention period of five weeks (phase B), subsequently followed by follow-up in the final week of re-testing (phase A2), where changes over the period were observed.

2.2 Measurements

The selected outcome measures were used to track changes over time within several stroke specific parameters of the International Classification of Functioning, Disability and Health, (ICF), (WHO, 2013), with each case acting as its own control.

The Motor Assessment Scale (MAS) was used to detect motor function of the upper extremity, the lower extremity, and balance aspects. The Dynamic Gait Index (DGI) outcome was used to assess the impact on dynamic balance during various walking activities. The Six Minute Walk Test (6MWT) provided a quantitative assessment of how far the participants could walk in six minutes up and down an office corridor with a track length of 40 meters. The Stroke Specific Quality of Life Scale (SS-QOL) questionnaire was used to assess participants’ subjective perception of their quality of life in the current situation, as well as to compare current and previous perceptions.

2.3 Participants

Four participants were selected for the project. All cases provided written informed consent to participation in the project. They were recruited from a fitness class at a rehabilitation facility in Denmark, and were accustomed to training intensively for 1½ hours twice per week. The inclusion criteria were that participants should have stroke in the chronic phase, be cognitively oriented in time, place and person, be able to make independent decisions, fill out questionnaires, and be able to communicate. Participants were required to be independent in transfers and to have an independent walking ability. Exclusion criteria were severe cognitive disorders, severe aphasia and lack of walking ability.

Case 1 is a man aged 64 years, measuring 178 cm, weighing 63 kg. Three years ago, he suffered an ischemic stroke in his right hemisphere after a middle cerebral artery infarct. The MAS only registered impaired motor function of his upper extremity, and his score in phase A1 was 37 out of 48 points. The DGI only found affection of his dynamic balance when he turned his head in the horizontal plane, where he had difficulty looking left, and the score was 23 out of 24. In 6MWT, he covered a distance of 552 m. The SS-QOL produced a score of 188 out of 245 possible points, indicating that his quality of life was affected.

Case 2 is a man aged 65 years, measuring 185 cm, weighing 83 kg. Three years ago, he suffered an ischemic right hemisphere stroke in the anterior part of the internal capsule and in part of the basal ganglia. The MAS registered impaired balance aspects in stair climbing, and his score was 47 out of 48 points. The DGI found affection of his dynamic balance when he moved his head in the horizontal and sagittal planes and when walking zigzag, where he avoided passing to the left of the cones. His score was 21 out of 24. In the 6MWT, he covered a distance of 563 m. The SS-QOL showed that quality of life was affected, since he obtained a score of 172 out of 245.

Case 3 is a man aged 70 years, measuring 170 cm, weighing 62 kg, who sustained a left-sided subdural hematoma 13 years ago, as a consequence of a traumatic brain injury. Subsequently, he suffered several minor cerebral infarcts. The MAS primarily registered impaired motor function of his upper extremity, but also an impact on the balance aspects when moving from supine to side lying, as well as in his sitting balance and when walking. His score was 29 out of 48 points. The DGI found affection of his dynamic balance in all subtests, except in zigzag walking. His score was 14 out of 24. In the 6MWT, he covered a distance of 143 m. The SS-QOL showed that quality of life was affected, since he obtained a score of 144 out of 245.

Case 4 is a woman aged 55 years, measuring168 cm, weighing 73 kg. Six years ago, she sustained a right-sided cerebral infarction. The MAS primarily registered impaired motor function of her upper extremity, since she has no volitional arm or hand function, but also an impact on the balance aspects, since she has difficulty moving from supine to side lying, as well as in her sitting balance and when walking. Her score was 26 out of 48 points. The DGI found affection of her dynamic balance. She uses a cane, and especially head movements in the sagittal plane and stair climbing were difficult. Her score in phase A1 was 16 out of 24. In the 6MWT, she covered a distance of 280 meters with a cane. The SS-QOL showed that her quality of life was affected, since she obtained 172 out of 245 points.

2.4 Intervention

The intervention was developed on the basis of a collaboration between the authors, the physical therapist, and the participants. A cyclical process founded on action research methodology was developed through continuous dialogue and adaptations of the exercises, thus continually ensuring that outcome fell within the scope of neuroplastic theory (see Fig. 1).

Over a period of five weeks, the intervention was applied in ten 1½ hour training sessions (two per week).

The topic of plasticity, and thus the entire project’s theoretical foundation, purpose and content in the form of ideas for intervention, was introduced to the participants at an introductory meeting prior to the intervention. In addition to explaining the plastic elements, the meeting was held to balance our expectations with respect to action research. The meeting gave rise to reflections among all participants, and the ensuing dialogue balanced our expectations, providing a framework for new reflections, which, in turn, influenced the following action: Launching the actual project.

The first action of the project became a common start through meditation. During the subsequent reflection, the participants expressed their appreciation of a common start, although they felt tired after meditating, since the “journey through the body” that they were introduced to required a lot of concentration. Some of the participants were observed to become so drowsy that they fell asleep during the action. This observation led to the following reflection: Since theory claims that meditation is conducive to neuroplasticity, meditation was not to be scrapped, but it was decided that the following action was to add an invigorating element to conclude the meditation.

The second action became that the participants patted their entire body in order to heighten their level of arousal. Patting had the desired effect, and after a few sessions of meditation, the participants began to say that they felt more ready for the exercises and aware of their bodies.

The third action. The participants having stated that they found it motivating to do something together, it was decided to introduce a common termination as the next action. The common termination comprised balloon games in a circle and sit-to-stand exercises. The observation found increased motivation, with participants encouraging each other by creating an invigorating element of competition. The observation was utilized in the reflection to develop the next action.

The fourth action became a scoreboard for the sit-to-stand exercise, where participants’ results were recorded for each round. In this manner, the cyclical components of action research, i.e. action, observation, and reflection, were put into play throughout the intervention.

In addition to the ten training sessions, home assignments on a daily basis were developed and continuously adjusted in order to increase the amount of training and intensity. Home assignments were task oriented and adapted to participants’ individual levels, needs and desires. To increase walking distance, all participants were equipped with a pedometer and were additionally given an inspirational sheet with tasks related to improvement of arm and hand function. The tasks progressed from exercises targeting the paretic hand to more challenging fine motor exercises.

By continually adding a few modifications with a neuroplastic focus, it was our desire that all participants in the project (i.e. the physical therapist, the “researchers”, and the participants) should have as much influence on the process of change as possible. The aim was that all participants should have a sense of ownership by clearly seeing that, through the circular process of action research, their reflections, opinions and ideas were heard, transformed into action and incorporated in the project. Figure 2 shows how specific elements of the theory of neuroplasticity were integrated session by session.

At the introductory meeting preceding the actual intervention, we explained the impact of diet and sleep on neuroplasticity. Diet and sleep are represented in all ten subsequent sessions because the participants were asked regularly about sleep and diet in order to maintain focus on the importance of these specific elements. Meditation was added as an element during the first training session. During the second intervention week, many repetitions and active participation were added as elements, and appropriately, the participants were given two home assignments: CD-guided meditation and hand exercises. The third intervention session emphasized promotion of participants’ motivation, in part by asking them specifically about individual goals, so that the focal point of consecutive sessions and home training would be linked to individual objectives. In the fourth intervention session, feedback was added as an element, among other things by carrying out awareness training in the corridor. While walking, participants were asked to name various objects which had been hung on both sides. They were given short verbal feedback for every time they noticed an object, and after the exercise, they were told the number of objects they had noticed and how many they had missed. The fifth and sixth training sessions did not add any new elements, but current exercises were progressed, so that participants continued to be challenged when performing the exercises. The seventh training session focused on music. Initially, the participants were asked about their tastes in music, and based on their preferences, a playlist was played during training. Training sessions eight through ten did not see addition of new elements, but merely made progressions of the currentexercises.

2.5 Procedure

Outcome measures were obtained for all four cases at the beginning and end of the intervention.

Phase A1 began after the introductory meeting, where the participants had been informed about the scope and content of the project.

Phase B did not comprise any tests, but through dialogue, evaluation sheets, field notes and observations, this phase followed the circular process of action research.

The follow-up phase A2 took place during the week after the conclusion of phase B. Outcome measures were again obtained in phase A2.

The procedure for data collection included an additional qualitative aspect, each case having repeatedly filled in an evaluation sheet designed as a questionnaire with open questions focusing on personal experiences regarding the general theme of neuroplasticity throughout the intervention period. Over the course of the intervention period, field notes were collected through participatory observation in order to obtain the four cases’ subjective perspectives on their development.

2.6 Analysis

Observation and reflection formed the basis for analysis and generation of new actions (Kildedal, Laursen, Duus, & Husted, 2012). Each case acted as its own control by comparing outcome measures from phases A1 and A2. Results were calculated numerically and as change in percent.

All collected qualitative empirical data were processed respecting the subjective statements and were checked for sincerity through dialogue with the four participants (Malterud, 2011).

3 Results

Individual data for the four cases for phase A1 and A2 outcome measures are listed in Table 1.

3.1 Case 1

3.1.1 MAS

Case 1’s performance improved by 6 points or 16% from a phase A1 score of 37 points to a phase A2 score of 43 points out of 48 points.

3.1.2 DGI

Although case 1 obtained an almost maximum score in phase A1, phase A2 showed a small improvement. The total score improved by 4% from 23 points (A1) to 24 points (A2) out of 24,

3.1.3 6MWT

There is only a slight improvement of 8 meters or 1% from the phase A1 distance of 552 m to the phase A2 distance of 560 m.

3.1.4 SS-QOL

An overall improvement of current quality of life of 9 points or 5% from a phase A1 score of 188 points to a phase A2 score of 197 points out of 245 points.

3.2 Case 2

3.2.1 MAS

Case 2’s performance improved by 2% from a phase A1 score of 47 points to a phase A2 score of 48 points out of 48 points.

3.2.2 DGI

An improvement of 3 points or 14% is found from 21 points (A1) to 24 points out of 24 (A2).

3.2.3 6MWT

There is a small improvement of 5 meters or 1% from the phase A1 distance of 563 m to the phase A2 distance of 568 m.

3.2.4 SS-QOL

In Case 2’s response to the SS-QOL, there is a clear improvement from phase A1 with a total score of 172 points to phase A2 with 229 out of 245 points. This is equivalent to an overall improvement of the current quality of life of 57 points or 33%.

3.3 Case 3

3.3.1 MAS

Case 3’s performance improved by 7% from a phase A1 score of 29 points to a phase A2 score of 31 points out of 48 points.

3.3.2 DGI

An improvement of 4 points or 29% is found from 14 points (A1) to 18 points out of 24 (A2).

3.3.3 6MWT

There is a clear improvement of 37 meters or 26% from the A1 distance of 143 m to the A2 distance of 180 m.

3.3.4 SS-QOL

Likewise, in Case 3’s response to the SS-QOL, there is a clear improvement from phase A1 with a total score of 144 points to phase A2 with 216 out of 245 points. This is equivalent to an overall improvement of the current quality of life of 72 points or 50 %.

3.4 Case 4

3.4.1 MAS

Case 4’s performance remained unchanged from phase A1 to phase A2, scoring 26 points out of 48 points on both occasions.

3.4.2 DGI

Case 4, however, does improve in the DGI. The improvement of the total score is from 16 points (A1) to 19 points (A2) out of 24, which is equivalent to an improvement of 3 points or 19%.

3.4.3 6MWT

Here we also find a change from phase A1 to phase A2, from 280 m (A1) to 299 m (A2), which is an improvement of 19 meters or 7%.

3.4.4 SS-QOL

An overall improvement of current quality of life of 5 points or 3% from a phase A1 score of 172 points to a phase A2 score of 177 points out of 245 points.

4 Discussion

Prioritizing and weighting of the project’s neuroplastic elements was based on our wish for the intervention to be as easily transferable as possible to other rehabilitation units, as well as to the domestic lives of persons with stroke. Consequently, we have consciously chosen not to include in the project intervention methods that are resource- and cost-intensive. This prioritization may have influenced the participants’ results negatively, since more costly interventions such as Virtual Reality (VR) and Robot Assisted Training were excluded.

It is impossible to say which part of the intervention that was responsible for improvements, since the project was carried out in a cyclical manner and consequently subject to repeated adjustments in accordance with the action research framework. In an intervention program, variables will always be present, contributing to bringing about changes, although they were not deemed to be catalysts for change initially (Jacobsen, & Rosenthal, 1977). One of these variables is the sense of community that arose among the participants as a result of their involvement in the project. The fact that they were specially selected may mean that the extra attention as well as the therapeutic enthusiasm that was present in connection with the research contributed to increasing their quality of life.

The results may also reflect the action research process per se, the process being characterized as a cooperative, problem-solving collaboration between participant and researcher, with a joint objective to problem solve and uncover new insights during the actual process. In 1996, Hammersley and Atkinson (Hammersley, & Atkinsin, 1996) wrote that action research conducts research with the field itself and not just within the field. When comparing this tenet with Launsø and Reiper’s (Launsø, & Rieper, 1993) description of action research, where cooperation between researcher and participant is one of the driving forces behind successful conduction of research, the outcome of this case report may be considered to stem from a particular research method.

Since the participants know they are being observed, a Hawthorne effect may occur (Jacobsen, & Rosenthal, 1977). Moreover, the participants are aware of the fact that implementation of neuroplastic thinking is being tried out, and that this may affect them. Continuous information about the underlying theory and research may also have expanded the participants’ horizons, and we must take into account that this may influence their behavior.

Due to participatory observation, the approach to and the study of the phenomenon have been characterized by presuppositions, capabilities and subjectivity. The intimate perspective of the approach was characterized by subjectivity, and it is conceivable that objective information collected from a more detached position would have produced a different picture.

A much debated aspect of case studies such as this one is whether a study that deals with the unique phenomenon can be implemented in a broader scope since its transfer value is limited, and consequently, the study ranks poorly in the evidence hierarchy. For these reasons, it is not possible to demonstrate external validity, but despite the absence of possibility of comparison, we can develop an understanding and coherence on the basis of behavior patterns (Jarvis, 2002).

Another critical aspect of the approach is the selection of a test battery. As previously mentioned, the participants are at diverse levels of motor functioning, which is why a floor or ceiling effect is found in MAS and DGI for several participants. Where the MAS is concerned, this test is not particularly useful for persons with either poor or relatively normal levels of motor function (Danske Fysioterapeuter, 2006).

Based on participants’ individual goals, it may be contemplated whether the selected tests are sufficiently sensitive to detect improvements in participants’ areas of choice. Since the goal of cases 2 and 4 was to improve sit-to-stand ability, the 30-Second Chair Stand Test subtest of the Senior Fitness Test would have been appropriate, perhaps combined with the Timed Up and Go test (TUG) (Danske Fysioterapeuter, 2012). The 30-Second Chair Stand Test, however, is not designed for stroke patients, and although the TUG has been tested for stroke patients, the norms for stroke patients would have produced a ceiling effect for cases 1 and 2.

As early as 1963, the Soviet neuropsychologist, AR Luria, was engrossed in the subject of brain plasticity (Luria, 1963). According to Luria, all brain activity depends on one or more functional systems. He made a distinction between functions at higher and lower levels of integration. Volitional motor function, nowadays ranked within the ICF component “body functions and structure”, takes place at a lower level of integration, since pure motor function is linked to a single functional system. In a more modern reading, this translates into deliberate movements being triggered by commands arising from a specific region of the primary motor cortex, that contains a huge number of highly specialized corticospinal neurons designated for precisely motor function. These neurons descend down the spinal cord, where they connect monosynaptically with anterior horn cells supplying the skeletal muscles with impulses (Foley, Mehta, Jutai, Staines, & Teasell, 2013). Consequently, we cannot expect other areas of the brain to compensate for lost motor function.

Motor function ranked within the ICF component “activities and participation”, according to Luria, takes place at a higher level of integration, since activities and participation involve multiple functional systems. Impairment of motor function at a higher level of integration can be exemplified by apraxia and neglect.

In rehabilitation, Luria distinguished between reorganization and compensation, both of which, in theory, could take place intra-systemically and inter-systemically, i.e. within the same or between distinct functional systems.

Luria found no evidence that impaired motor functions at lower levels of integration were susceptible to intra-systemic reorganization, since neuroplastic changes could not be expected to occur in the underlying functional system (the damaged part of the motor cortex). Intra-systemic compensation, on the other hand is feasible, e.g. by letting the contralateral side take over those components of a motor function that can no longer be performed by the affected part of the motor cortex.

According to Luria, the situation is different when it comes to impaired motor functions at higher levels of integration. Here, both intra- and inter-systemic reorganizations and compensations can take place to restore motor function.

The fact that some of the participants improve in some of the tests can probably be ascribed to the fact that intra-systemic compensation took place through greater involvement of the less affected side, and that an inter-systemic reorganization or compensation occurred, resulting in improved attention, focus and drive. It is hardly likely that an intra-systemic reorganization took place, since none of the participants became less paretic in the course of the intervention. Indeed, this was not to be expected, all participants being in the chronic phase, where research regarding the effect of rehabilitation on neuroplasticity rarely finds structural changes in damaged brain structures (Mogensen, 2011). This probably explains why case 4, for instance, did not improve on the three subtest of the MAS that deal with hand and arm function.

The optimal method for detecting neuroplastic changes would be a brain scan of the participants before, during and after the intervention, but this was beyond the scope of this study. Whether a functional improvement can be ascribed to structural changes or reorganization may be of scientific interest, but to the participants, the perceived improvement of performance at the level of participation is what matters. The test battery used in this study does not comprise tests at the level of participation, beyond the SS-QOL, where two participants experienced significant improvement, which can probably be seen as the most important effect of the intervention.

A group of matched controls would have permitted us to enunciate with greater probability whether the improvements were attributable to the intervention per se or to training in general.

In this multi-case study, the measurements converge case by case, since all tests support the same conclusion, viz. that there has been an improvement. When the results of the individual case studies are compared with each other, convergence is also found across cases. Since all four analyses indicate improvements, this strengthens the theory of the applicability of neuroplasticity in neurological rehabilitation programs for people with chronic stroke.

There is a trend toward improvement in all the participants that indicates that these four chronic stroke patients hold a potential for training. All participants have engaged in the process of action research, a fact that in its own right can be regarded as a positive result of the project.

Whether the trends we found can be ascribed to neuroplastic changes or are attributable to the inherent mechanisms of action research remains uncertain. This occasions us to consider the applicability of action research as a viable method within neurorehabilitation as well as the feasibility of implementing a neuroplastic focus within the profession of physical therapy.

5 Conclusion

This study describes four cases with chronic stroke and varying degrees of cognitive and motor sequelae. Over the course of an intervention period, the aim was to examine whether an added neuroplastic focus could lead to improvements in the participants. Baseline tests compared with final tests, showed a tendency toward improvements of motor function and improved quality of life. This tendency was especially clear in case 3 where all tests showed improvement. Furthermore, an improvement in quality of life (SS-QOL) was found in cases 2 and 3. The ambition of this case study has been to provide a description of the method that is sufficiently precise to permit the results to form a basis for hypothesis generation that can be used in future research.

The study has led to insights, increased knowledge and an improved understanding of the implementation of neuroplastic theory and the applicability of action research in rehabilitation in physical therapy. The trends observed in the course of the intervention indicate that stroke patients, in spite of their chronic condition, retain a training potential, especially with regard to exercises involving activities and participation where many elements are at play simultaneously. The trends also raise consciousness with regard to possible changes in physical therapists’ approach to and organization of training for this particular group of patients.

The detailed description of the method allows the study, or elements of it, to be inspirational or to be implemented in current practice. The method can be generalized directly to physical therapy rehabilitation with stroke patients, as well as to other types of rehabilitation with other patient groups, where the need to embrace neuroplasticity in the manner of meaningful, repetitive and task-oriented training is no less important.

Given the specific and context-dependent situation, it is, however, beyond the scope of this study to provide precepts for an ideal implementation of neuroplastic conditions. On the basis of this study, it would be desirable to develop the concept further in order to implement the approach in the clinical practice of physical therapists, and to develop training opportunities based on larger studies. In the course of further development, it would be appropriate and relevant to include other professions, since interdisciplinary approaches can reinforce neuroplastic implementation. In this context, the present study can also be considered a pilot project.

Conflict of interest

None.

Footnotes

Acknowledgments

The authors wish to thank the four participants. The research has not been supported by any grants.

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