Author(s): Sarah Hunton, MD, Rani Gardner, MD, Suzanne Abou-Diab, MD, Bilal Ahsan
Originally published: October 3, 2012 Last updated: January 3, 2024
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 stimulation13-15
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 Therapy13,19
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 rehabilitation16,24
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 1/3rd 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
