Stroke and Other Cerebrovascular Disorders Part Two: Rehabilitation Management and Treatments

Hopefully your doctor is well versed in everything here. Nothing here tells you the effectiveness of these treatments so I can only assume they barely work!  If they worked they would be shouting it from the rooftops!

Stroke and Other Cerebrovascular Disorders Part Two: Rehabilitation Management and Treatments

Author(s): Sarah Hunton, MD, Rani Gardner, MD, Suzanne Abou-Diab, MD, Bilal Ahsan

Originally published: October 3, 2012 Last updated: January 3, 2024

Jump to: Disease/disorderEssentials of AssessmentCutting Edge/emerging and Unique Concepts and PracticeRehabilitation Management and TreatmentsGaps in the Evidence-Based KnowledgeReferences

Disease/disorder

See Cerebrovascular Disorders Part 1.

Essentials of Assessment

See Cerebrovascular Disorders Part 1.

Cutting Edge/emerging and Unique Concepts and Practice

Constraint-induced movement therapy (CIMT)^1,2

Traditional CIMT involves restraint of the unaffected limb for 90% of the waking hours for 14 days while intensively training the use of the affected arm during 4-6 hour sessions. A modified version exists (mCIMT) during which the unaffected arm is only restrained for 5-6 hours per day; it is less time consuming and a more appealing option for patients and therapy team members. A number of studies have shown that CIMT induces a use-dependent increase in cortical reorganization of the areas of the brain controlling the more affected limb.^3,4 Studies have demonstrated significant improvements in motor and functional outcomes, although there have been mixed results. CIMT is shown to be effective in patients who have active wrist extension (at least 20 degrees), active finger extension (at least 10 degrees), good cognition, limited spasticity, and preserved balance. CIMT has shown effectiveness in improving motor function in both the acute and chronic phases of stroke recovery, but studies have been limited by small sample sizes.  High volume CIMT combined with electrical stimulation with task-specific training and strength training have been shown to be the most effective interventions in improving upper limb motor function in individuals with stroke. ⁵

Bilateral upper extremity training

This training is a stroke rehabilitation technique that has been applied to patients in both acute and chronic post-stroke phases. Investigators have recommended that patients in the chronic phase poststroke who retain at least a minimal degree of corticospinal integrity (as reflected by, e.g., active finger movements) should receive unilateral training, and those with little or no distal movement might benefit more from bilateral training. For those stroke patients without corticospinal tract integrity, targeting the contralesional hemisphere using bilateral training is expected to be more appropriate, although the functional gains are expected to be small.⁶

Body-weight-supported (BWS) therapy⁷

This modality allows stroke patients to safely participate in task-specific gait training. A harness provides support of body weight over a treadmill or other surface, while a therapist can observe and correct any unwanted gait pattern. BWS treadmill training can be done with or without visual feedback however no significant difference in functional improvements have been found with the presence or absence of visual biofeedback.⁸ BWS gait training has been shown to improve ambulation in hemiparetic stroke patients producing a more symmetric, efficient hemiparetic gait pattern. However, superiority of BWS therapy over conventional post-stroke gait training therapies has not been established.

Robotics⁹

Robotic devices are ideal for the repetitive exercises that are often used to facilitate motor relearning and strengthening after stroke. Used for both upper and lower limb rehabilitation, newer robotic software makes previously tedious and repetitive tasks more engaging by incorporating gaming and other challenges. Many newer robotic devices have the added benefit of being able to collect data for the rehabilitation team. Similar to most emerging therapies, there are barriers to use which include limited studies supporting benefit, high cost, and limited knowledge of using the technology.

Brain-computer interface (BCI)^10–12

BCI’s have evolved from assistive technologies allowing those with severe motor impairments (e.g., locked-in syndrome, stroke, amyotrophic lateral sclerosis) avenues to control devices for mobility and communication to newer neurorehabilitation tools allowing patients with severe motor deficits to participate in the rehabilitation process. BCI involves developing neuroprosthetic devices and technologies to bypass damaged brain tissue via adaptive neuroplasticity of uninvolved distal brain areas. Parts of the nervous system not involved in specific tasks can be harnessed to reconstruct the neural substrate that interacts with a BCI-driven devices. A brain-machine interface uses brain signals to drive external devices without the use of peripheral physiologic activities. Barriers to use are high cost and unreliable technology.

Noninvasive Brain Stimulation (NIBS) – Transcranial magnetic and direct current stimulation^13-15

This therapy involves applying mild magnetic or electric stimulation to the scalp. The benefit is thought to be achieved by neuromodulation of plasticity and cortical excitability. A growing number of studies support its therapeutic potential and safety in stroke rehabilitation and have shown to improve motor function, gait, language (aphasia) and cognitive (neglect) deficits, and mood. A meta-analysis reported that even though there are gait, balance, and lower limb function improvements across NIBS, the results vary based on the type of stimulation technique, the location of stimulated area, as well as the protocol used, warranting further in-depth research.¹⁵

Mental Practice (MP)/Motor Imagery¹³

This refers to mental rehearsal of a movement. Imaging studies have shown that this motor imagery stimulates overlapping cortical areas as the actual movements. Most studies have shown a positive effect on upper extremity function. A recent Cochrane Review found MP in combination with routine rehabilitation is more effective in restoring arm function compared to rehabilitation alone.¹⁷ A recent systematic review concluded that MP/MI used on its own is not effective, but it is shown to be effective in recovering upper limb motor movements, speed and coordination of such movements when used in conjunction with conventional and non-conventional therapies. There is still further research needed to establish assessment tools to analyze the efficacy of this therapy as well as to quantify the progress being made when used on its own.¹⁸

Mirror Therapy^13,19

Initially applied to amputation patients, this therapy involves placing a mirror in the mid-sagittal plane, allowing the patient to visualize the reflection of the non-paretic limb as if it were the paretic limb. The underlying theory is that there is cortical activation of the injured region of the brain from the perception of movement via interhemispheric communication.  Though there are studies have showing gains in motor function, there is limited evidence in the stroke population prompting routine use.¹⁶

Virtual reality (VR)²⁰

Virtual environments and objects provide the user with visual feedback and repetitive skills practice. The interface may be through a head-mounted device, projection systems, or involving sensations of hearing, touch, movement, balance, or smell. The user interacts with the environment by devices, such as a mouse or joystick, or more complex systems using cameras, sensors, or haptic feedback devices. A 2017 Cochrane review²⁰ found evidence that VR and interactive video gaming may be beneficial in improving upper limb function and ADL function as an adjunctive therapy or when compared with the same amount of standard therapy. There was insufficient evidence to make conclusions about the effect on grip strength, gait speed or global motor function. A randomized control trial observed a significant improvement in cognitive flexibility and shifting skills, selective attention/visual research, and quality of life with regard to perception of mental and physical state in stroke patients when VR and robotic exoskeleton were used in combination.²¹

Rehabilitation Management and Treatments

Current treatment guidelines(Survivors don't want useless guidelines! They want EXACT PROTOCOLS THAT DELIVER 100% RECOVERY! GET THERE!)

The American Heart Association (AHA) & American Stroke Association have published guidelines for the management and rehabilitation of stroke.^22–25

Acute stroke management

• Emergency noncontrast computerized tomography (CT) scan of the head is performed to differentiate between ischemic and hemorrhagic stroke.
• Intravenous thrombolysis with recombinant tissue plasminogen activator (rTPA) is indicated for adults with diagnosis of ischemic stroke in the absence of contraindications, provided it can be administered within 4.5 hours of symptom onset.^23,26
• Endovascular techniques (e.g., thrombectomy or intra-arterial fibrinolysis) are recommended for selected patients within 16-24 hours for those with large vessel occlusion in the anterior circulation > 6 hours.^13,23,26 rTPA should still be administered in eligible patients.^1,7 Intracranial vascular imaging (CT angiogram or MR angiogram) is recommended if endovascular therapy is contemplated.²⁷
• Initiation of aspirin within 24-48 hours is indicated for ischemic strokes.²³ Patients with acute ischemic stroke who are allergic to or intolerant of aspirin should be given an alternative antiplatelet agent (e.g. clopidogrel).
• Initial management of intracerebral hemorrhage (ICH) includes reversal of any identified coagulopathy and monitoring/lowering of intracranial pressure, if increased. Surgical evacuation is generally not indicated for supratentorial hemorrhage but is recommended for cerebellar ICH with brainstem compression or hydrocephalus.²⁶
• Comprehensive stroke centers and stroke systems of care(NOT RESULTS OR RECOVERY! So useless!) improve(NOT GOOD ENOUGH!) outcomes through prevention and treatment of stroke, as well as post-stroke rehabilitation.^23,24,26

Acute and post-acute stroke management and rehabilitation^16,24

Early initiation of rehabilitation after acute stroke is associated with shorter rehabilitation length of stays and improved functional outcomes.²⁴

The goals of rehabilitation include prevention of complications, minimizing functional impairments, and maximizing function recovery. Initial rehabilitation efforts should start as soon as possible in the acute care setting then transition to the inpatient rehabilitation setting. Other levels of post-acute care include sub-acute inpatient rehabilitation, day rehabilitation programs, outpatient programs, and home therapy programs.

Rehabilitation involves a multidisciplinary team that is often led by a rehabilitation physician. Depending on functional impairments and patient needs, the team often includes:

• Physical therapy: evaluation and rehabilitation of mobility including stretching, range of motion, strengthening, balance, endurance, transfers, standing, and ambulation
• Occupational therapy: evaluation and rehabilitation of self-care skills including treatment of impairments related to activities of daily living and upper extremity impairments
• Speech and language pathology: evaluation and rehabilitation of cognitive, language, and swallowing impairments
• Neuropsychology: Psychological support and cognitive assessment and interventions
• Nursing: Assistance with bed mobility and positioning, bowel and bladder management, skin care, education
• Recreational therapy: community integration, functional cognitive tasks (games, music, social interaction, etc.)
• Social work/Case management: Discharge planning, resource and benefits counseling, and guidance/education
• Other disciplines: vocational rehabilitation specialist, dietician, pharmacist

The rehabilitation physician and team play a significant role in minimizing complications

• Early mobilization: Minimizing deconditioning and its associated effects on fatigue, orthostatic hypotension, and endurance.
• Evaluation and treatment of dysphagia: Dysphagia is common and increases risk of pneumonia. A formal swallowing assessment is standard of care for determination of the safest diet consistency/texture to minimize risk of aspiration; aspiration is missed on bedside swallow study in 40-60% of patients. Screening should be performed before any oral intake. Dynamic instrumental assessment with a videofluoroscopy swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) can help guide rehabilitative techniques.
• Nutrition status: Adequate nutritional status, including adequate hydration, should be ensured by monitoring intake (consider formal calorie counts), body weight, and laboratory tests (e.g., albumin or prealbumin).
• Blood glucose levels: Monitor for at least 72 hours post-stroke. Hyperglycemia or hypoglycemia should be treated adequately. Blood glucose should be maintained between 140-180 mg/dl.
• Blood pressure management:^{25,26,29–31} There is controversy about optimal blood pressure levels in the acute stage and concern about adverse effect on collateral circulation in the brain with rapid lowering of blood pressure. It is reasonable to restart or initiate antihypertensives during acute hospitalization with pressures greater than 140/90mmg HG once neurologically stable and it is suggested that lowering blood pressure no more than 15% during the first 24 hours is reasonable when values are significantly elevated (greater than or equal to 220/120mmHG).
• Spasticity: Prevention and early detection are important. Prevention measures include early mobilization, range of motion, proper positioning, and use of braces, if needed. Medications include tizanidine, dantrolene, and baclofen.  Botulinum toxin or intrathecal baclofen should be considered for selected patients. Contractures can be treated using splinting, serial casting, or surgical correction. Diazepam and other benzodiazepines should be avoided during the stroke recovery period because they may delay recovery. Those who have spasticity in their upper or lower limbs after stroke should not be treated with electrical stimulation to reduce spasticity unless after botulinum toxin injection to wrist or fingers as an adjunct to splinting.³²
• Deep vein thrombosis (DVT) prophylaxis: Preventative measures include early mobilization, pharmacological prophylaxis with subcutaneous heparin or low molecular weight heparin (unless contraindicated), and pneumatic compression devices or graduated compression stockings. An inferior vena cava filter may be considered in patients at risk for pulmonary embolism if anticoagulation is contraindicated.
• Shoulder pain: Prevention of post-stroke shoulder pain and subluxation is done through careful monitoring, proper positioning, hemiplegic limb support including use of wheelchair arm trough, shoulder harness/sling or taping, trauma prevention, avoidance of uncontrolled abduction and overhead pulley use, and precautions during transfers. Shoulder subluxation and pain may be treated with oral medications, intra-articular steroid injections, shoulder support, arm trough or lap tray, stretching, thermal modalities, functional electrical stimulus, spasticity management, or referral for suprascapular nerve block.³³
• Bladder management: Urinary incontinence is a common post-stroke complication but often resolves over time. Urinary retention can be assessed with use of a bladder scanner or an in-and-out catheterization. Timed voids and temporary use of external or intermittent catheterization may be helpful. Indwelling catheters increase risk of urinary infection and prolonged use should be avoided whenever feasible.
• Bowel management: Incontinence is less common than constipation or fecal impaction. Discussion regarding improved diet, fluid intake and exercise as well as medication review for constipating medications is encouraged. A bowel regimen involving the use of laxatives, stool softeners, and bowel training should be initiated.
• Skin: Skin integrity should be assessed on admission and monitored daily. Skin breakdown risk may be assessed with standardized tools, such as the Braden Scale. Preventative interventions include special mattresses, frequent turning, proper positioning, transfers, lubricants, barrier sprays and ointments, spasticity management when appropriate and protective dressings.
• Medication considerations: Central nervous system (CNS) depressants, such as neuroleptics, benzodiazepines, and barbiturates, may be associated with poorer outcomes and should be avoided whenever feasible.
• Post-stroke depression: Up to 1/3^rd of all stroke patients will experience depression during their recovery process. Early diagnosis and treatment is recommended as stroke outcomes have been shown to be negatively affected and may even increase risk of recurrent stroke.³¹ Depression may be related to neurotransmitter depletion from stroke lesions and/or psychological response to physical/personal losses associated with stroke. Selective serotonin reuptake inhibitors are the preferred medication when appropriate and should not be given routinely for prevention of depression without evidence of increased risk due to increased potential of adverse effects.³⁴ Several studies suggest neural mechanisms of recovery may be facilitated by certain antidepressants.²⁸ Other emerging treatment approaches include electroconvulsive therapy, acupuncture, music therapy, and nutraceuticals.²⁹ Further studies are needed in these emerging areas.
• Fall risk: Fall risk should be assessed using established tools and prevention strategies utilized. Strategies include low beds, bed alarms, wheelchair belts, and patient/caregiver education.
• Infection: Fever should be reduced promptly. Pneumonia and urinary tract infections should be prevented and promptly identified and treated if they occur.
• Specific rehabilitation interventions: Rehabilitation interventions are based on comprehensive, standardized assessments for impairments (motor, sensory, cognitive, communication, swallowing, psychological, and safety awareness) and prior/current functional status.
  • Motor assessment should be at both the impairment and functional level. Components should include strength, active and passive range of motion, tone, gross and fine motor coordination, balance, apraxia, and mobility. Motor function is addressed with strengthening, balance and gait training, orthoses, transcutaneous electrical nerve stimulation (TENS), robot-assisted movement therapy, constraint-induced movement therapy, and body-weight-supported treadmill training, and upper extremity interventions in order to improve activities of daily living.⁶ Functional electrical stimulation may help facilitate movement or compensate for lack of voluntary movement.
  • Sensory assessment should include an evaluation of different sensations (sharp/dull, temperature, light touch, vibratory and position), a vision exam, and a hearing exam if hearing impairment is suspected. Compensatory techniques for sensory impairments should be included in the stroke patient’s individualized rehabilitation program.
  • Cognitive assessment should address arousal, attention, visual neglect, learning, memory, executive function, and problem solving.
  • Psychosocial assessments should be made of psychological factors (e.g., pre-morbid personality, level of insight, loss of identity concerns, sexuality), psychiatric illnesses, available resources, social support, patient goals, life situation, and social roles. A home assessment may be needed.
  • Management of dysphagia includes postural changes, increased sensory input, modified swallowing maneuvers, active exercise programs, and diet modifications. Non-oral feeding may be required in some instances, including consideration of percutaneous endoscopic gastrostomy feeding.
  • Aphasia management includes early recognition and development of a multidisciplinary focused treatment plan to increase gains during spontaneous recovery and use of compensatory techniques for persistent communication problems. Dysarthria treatments include interventions to improve articulation, fluency, resonance, and phonation, compensatory techniques, and use of alternate/augmentative communication (AAC) devices. Personalized, telerehabilitation programs as supplementation to in person rehabilitation as shown to be beneficial for those limited by insurance, transportation or limited providers.³⁵
  • Cognitive deficits are common and can include impaired memory, concentration and executive function. Deficits can be managed through patient, family, and staff education of deficits, teaching compensatory strategies and structured feedback.
  • Measures to address visual and spatial neglect should be integrated with other therapies, and may include prism glasses, increased awareness of deficits, and compensatory techniques.
  • Neuropsychiatric sequalae should be identified and treated. Acetylcholinesterase inhibitors or the NMDA receptor inhibitor, Memantine, can be considered for patients with vascular dementia or vascular cognitive impairment.²⁷ Amphetamines are not recommended to enhance motor recovery.²⁷
  • Patient, family, and caregiver education is an integral part of rehabilitation, as are appropriate advocacy and identification and help with securing of available support and resources. Assessment findings and expected outcomes should be discussed with the patient and family/caregivers.

Chronic stroke management

• Rehabilitation team members should provide adequate support as the patient transitions from inpatient rehabilitation to home. Team can provide assistance with ordering appropriate durable medical equipment (DME), instructions for home rehabilitation programs, arranging for home health or outpatient therapy services, scheduling follow up medical appointments, and providing information on local stroke support groups.
• Ongoing management may include a regular exercise program, walking aids and/or wheelchair, adaptive devices for activities of daily living, home modifications, addressing return to work, driving, management of sexual dysfunction, and ongoing evaluation and management of stroke risk factors and comorbid conditions. Appropriate safety measures (e.g., fall prevention) should be instituted.⁴
• Secondary prevention of stroke:³⁰ Appropriate treatment of hypertension, anticoagulation for atrial fibrillation thrombo-embolic prophylaxis, use of antiplatelet therapy in cerebral ischemia, prevention of coronary heart disease, lipid lowering therapy, exercise, and smoking cessation are all important. Blood sugar maintenance of near-normoglycemic levels (80-140 mg/dl) is recommended for long-term prevention of microvascular and macrovascular complications.

Coordination of care

Coordination of treatment care plans should include all involved medical specialists-including the primary care physician, home care services, outpatient therapists, and the patient and their care givers. A multidisciplinary team is essential for success.

Patient & family education

Education must focus on management of risk factors, maintenance of rehabilitation gains, preventing complications, community support and resources, home modifications, and community reintegration.

Key topics for stroke prevention education (also see “Secondary prevention of stroke” section above):

• Modifiable risk factors include hypertension, heart disease, diabetes, obesity or being overweight.
• Recommend: smoking cessation, avoiding excess alcohol consumption, having a balanced diet, and exercise participation.

Key topics for post stroke complication education and prevention

• Maintain regular follow up with a primary care physician to prevent and monitor for complications.
• Monitor for signs and symptoms of post stroke complications: depression, spasticity or contractures, shoulder pain/subluxation, DVTs, pressure ulcers, pneumonias, seizures, osteoporosis, UTIs and/or bladder control.
• The following treatment or preventative techniques may be employed:
  • Counseling, psychotherapy, local stroke support groups, and antidepressant medications may be utilized for depression.
  • Range of motion exercises and physical therapies can help prevent limb contractures and shoulder pain.
  • Good nutrition and frequent pressure relief, including turning while in bed, will help prevent pressure ulcers.
  • Swallowing exercises and precautions, deep breathing exercises, and respiratory therapy can minimize risk of pneumonia.
  • Bladder training programs may be helpful for poor bladder function control.

Outcome measures

Functional status, discharge disposition (i.e., home versus facility), hospital readmissions, and mortality are important indicators to measure in the post-discharge period.

Common scales

• Functional Independence Measure Scale (FIM): Assesses physical and cognitive function focusing on burden of care. There are a total of 13 motor items and 5 social-cognitive items. Each item is scored from 1-7, with 7 indicating complete independence.
• Modified Rankin Scale: A global outcome scale that runs from 0-6, with 0 being perfect health without symptoms, and 6 being death. It is commonly used for measuring the degree of disability, or dependence, and has become a widely used clinical outcome measure for stroke clinical trials.

Gaps in the Evidence-Based Knowledge

• Although several different forms of rehabilitation techniques have been proven effective, these studies often involve small and highly selective populations and are not generalizable to the stroke population.
• Further studies are needed to develop optimal treatment protocols evaluating for ideal patient population(No survivor should be left behind, they all want 100% recovery! Why the hell isn't that your goal?), ease of treatment program, and combined modalities for many of the therapies, including constraint-induced movement therapy, indirect brain stimulation, and mirror therapy.
• Blood pressure management during early stroke management continues to be an area of conflict. Larger trials with well-defined criteria are needed and appear to be forthcoming. Current guidelines should be followed until such time.²⁵
• The most recent AHA guidelines suggest further study is needed in specific areas of early acute ischemic stroke management, including in intravenous fibrinolysis, endovascular interventions, anticoagulants, antiplatelet agents, and induced hypertension.²⁶
• The use of complementary and alternative medicine (CAM) in cardiovascular disease and stroke patients has gained in popularity over recent years and appears common. These include biological therapies such as dietary supplements, herbal medicine, and aromatherapy; mind-body therapies such as deep breathing, meditation, yoga, tai chi, and praying; manipulative and body-based therapies such acupressure, chiropractic manipulation, massage, osteopathic manipulation, and reflexology; whole medical systems which include acupuncture, Ayurveda, homeopathy, and naturopathy; and finally energy medicine which includes healing touch, light therapy, magnetic therapy, Reiki, and sound energy therapy. Biologic, mind-body therapies, and acupuncture (especially among stroke patients) are the most commonly used. Potential interactions and adverse effects may exist for biological CAM therapies. Further studies are needed, especially in regard to effects of CAM therapies on clinical outcomes and safety, particularly in stroke patients.^31,36
  

References at link.