Applied Behavior Analysis in Post-Stroke Therapy

Applied behavior therapists work with stroke patients in rehabilitation to help them deal with emotional and related behavioral issues resulting from debilitation in brain function. Behavioral learning is used to retrain many types of common activities from speech to self-care to emotional well-being.

For many, it starts with slurred speech. A perfectly ordinary sentence, one that might have rolled off the tongue effortlessly a few minutes earlier, suddenly comes out of their mouth sounding like gibberish. It’s a momentary tic, they think—they’ve just become tongue-tied, tripped over a few syllables as we all do from time to time.

Then they notice an inexplicable weakness in one arm of the other—it seems too heavy too lift. The person they are talking to starts to look alarmed. “What’s wrong?” they ask. “Your expression looks like you just tasted something terrible!” It’s because one side of the face has lost muscular control and begun to droop… deep inside the brain, a blood vessel has been blocked, or burst, causing a sudden decrease in blood flow that causes brain function to cease.

They are having a stroke.

Almost 800,000 people in the United States have a stroke (or Transient Ischemic Attack, TIA) each year, and around 140,000 of them die. But that leaves more than half a million stroke victims in some state of recovery every year who require sometimes intensive rehabilitation to regain normal function and behavior.

Applied behavior analysts (ABAs) are a critical part of stroke rehabilitation teams. Damage done to the brain during transient ischemic attacks can radically alter personality and behavioral traits, often resulting in issues such as:

  • Anxiety
  • Depression
  • Aggression and non-compliance
  • Lack of motivation

Those issues may be due to neural damage from the TIA itself or simply psychological byproducts of undergoing a traumatic injury. In either case, ABAs use their training to assess the functional issues facing the patient and apply operant conditioning techniques to help retrain them to improve function and quality of life.

Retraining the Brain Using Operant Conditioning

The saving grace for many brain injury patients is a quality of that organ known as neuroplasticity. Neuroplasticity is the ability of regions of the brain to repurpose themselves to take on new functions, allowing healthy brain matter to take over the function of damaged regions.

For ABAs, however, the brain chemistry is not the focus. Operant conditioning techniques rely exclusively on observing and modifying observable behaviors using the antecedents (the surrounding environmental factors leading to the behavior) and consequences (the outcome of the behavior in terms of effects on that environment).

An ABA will begin working with a stroke patient by conducting a Functional Behavior Analysis (FBA) to assess problematic or deficient behaviors. This can include the expressions of the psychological issues mentioned above, such as extreme and socially inappropriate mood disorders. It can also include previously normal functional behaviors, such as feeding or bathing oneself, that the patient is no longer able to perform.

The ABA may observe the patient directly, work from records or notes compiled by other medical professionals, or interview the patient to complete the FBA.

With the FBA completed, the ABA will have established a set of working theories about the conditions facing the patient. In stroke patients, issues can occur either because of loss of basic skills from the destruction of related brain regions, or because of psychological issues resulting from the trauma. For example, a stroke patient who has stopped brushing their teeth might have lost either the related motor function to perform the task, or instead lost the social conditioning and expectation providing the drive to engage in the task.

It’s up to the ABA to determine which antecedent is at issue and form a plan, called a behavioral intervention plan, or BIP, to address it. Although psychological issues are more traditionally in the wheelhouse of behavior analysis, recent research has suggested that a technique called constraint-induced movement therapy can help retrain function even in cases of physical disability. The method involves intentionally disabling functional limbs and essentially forcing the brain to rely on the stroke-affected limb to work with.

The BIP will usually include adjustments to both environment and consequences in order to reward the desired behavior. Verbal praise or other social cues can be offered as positive reinforcement, or environmental modifications can be made to overcome physical hurdles that the debilitation might create.

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Behavior Analysts Fill an Important Role on the Rehabilitation Team

The ABA does not perform any of these tasks in isolation. Stroke therapy is a multifaceted, team-based treatment, involving other healthcare professional such as:

  • Physicians
  • Neurologists
  • Nurses
  • Physical Therapists
  • Occupational Therapists
  • Speech Language Therapists

A behavior analyst will work with all of these other roles in various aspects of treatment. For instance, a neurologist may be able to provide vital information about the regions of the brain that have been damaged and the related functions that provide important source information for the FBA. When formulating the BIP, the ABA will probably work closely with the other therapists on the team to establish goals and priorities that serve each of the respective fields. Finally, the ABA will expect all of the other caregivers who regularly interact with the patient to help maintain the standards of the BIP to maintain consistent reinforcement throughout the patient’s treatment.

The ABA might be involved as early as the acute care phase, soon after the attack, working in a hospital or specialty care facility. More frequently, behavior analysts are employed in long-term care or rehabilitation facilities. When patients recover to the point where a return to regular home life becomes feasible, the ABA may conduct home visits and work with family members to help them understand and continue the BIP.

How to Prepare for a Career Working with Stroke Victims as an Applied Behavior Analyst

You will need a master’s degree or higher in order to practice as an ABA working with stroke victims. The degree is a necessary precursor to the certification that most rehabilitation facilities and hospitals look for in ABAs, the Board Certified Behavior Analyst (BCBA®) certificate from the Behavior Analyst Certification Board. The BCBA® requires a master’s or better in psychology, education, or applied behavior analysis, or additional coursework focused on behavior analysis if your degree is in an unrelated field.

Stroke victims tend to be older, on average, so some experience with geriatric populations is a plus. Volunteering in nursing homes or other facilities with high proportions of elderly patients can help you prepare for some of the ancillary conditions you will be likely to encounter in post-stroke rehabilitation.

A strong medical background is usually important for ABAs working with stroke victims. Understanding the mechanisms of damage and the medical treatments that will be given to the patient can be important in creating appropriate behavioral intervention therapies. Undergraduate degrees in pre-medicine or biology may be useful.

There are two specialty certifications that ABAs can acquire to gain knowledge and expertise for stroke treatment:

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Further Resources on Applied Behavior Analysis in Post-Stroke Therapy

Brain Injury Association of America – A non-profit organization dedicated to advancing awareness, treatment, research, and education to improve the quality of life of patients and families impacted by strokes and other brain injuries.

Brainline – An overview of ABA techniques commonly applied in brain injury cases.

Association for Behavior Analysis International Special Interest Groups – Stroke specialists might find the Rehabilitation and Independence SIG and the Neuroscience SIG useful for up-to-date professional information on ABA stroke therapies.

The National Stroke Association – A non-profit group that provides resources for stroke victims, their families, and treatment providers.

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