Stroke Rehabilitation

Stroke Rehabilitation Fifteen–Twenty High-Yield Points Definition and conceptual framework

Stroke is the leading cause of severe physical disability in adults. Rehabilitation is defined as a multidisciplinary problem-solving educational process focusing on disability and intended to reduce handicap — it is not simply treatment by a therapist or group of therapists.

The WHO/ICF framework underpins assessment: impairment (loss of structure or function), disability (inability to perform tasks — the ability to undertake basic self-care is fundamental to any physical rehabilitation programme), and handicap (the social consequence, i.e. limitation in fulfilling a normal role in society). Disability and handicap are often combined pragmatically as social disability.

Four basic principles: document and measure impairments, disabilities and handicaps using simple valid scales; maximise independence and minimise learned dependency; adopt a holistic approach covering physical and psychosocial background, support mechanisms and environment; and support caregivers, helping them develop the physical and psychological skills for long-term sustainable care.

The brain is capable of significant recovery after stroke, provided appropriate treatments are applied in adequate amounts and at the right time. Recovery depends on resolution of oedema and penumbral salvage early, then on neuroplasticity — cortical reorganisation, unmasking of latent pathways, synaptogenesis and stroke-induced neurogenesis.

The more severe the initial deficit, the less likely complete recovery. The pattern is not uniform, varying between individuals and between different deficits in the same individual, and there is no validated method for predicting the precise mode or degree of recovery for a given individual.

Rates of recovery differ by deficit: homonymous hemianopia, dysphagia and sitting balance resolve quickly; arm paralysis and language impairment recover more slowly and less completely; perceptual problems may persist or take very long. Overall, 62% are independent in self-care at three months and 66% at one year, despite persisting neurological deficit in some.

Day-to-day variation may mask recovery or give false optimism, so monitor trends over time rather than relying on one-off assessments. Comorbidity and stroke-related complications adversely affect recovery. Spontaneous recovery may not plateau until six months, which is the most appropriate time point for measuring neurological and functional outcome; participation and life satisfaction are best measured once the social situation has stabilised. The four components of the rehabilitation process

Assessment defines the nature and severity of deficits and treatment goals before starting. Its three purposes are prognostication (type of patient, extent of disability, potential for recovery), identifying the main problems and the expectations of patient and family, and monitoring and outcome evaluation. Measures must be valid, reliable, sensitive, simple and communicable, and existing measures should be used wherever possible.

Composite global severity scores are unreliable because speech and language function dominates the index, and because combining very different disabilities into one score loses specific information and ignores their interactions.

Predicting when a patient has reached full recovery potential is an imprecise science, and matters most for chronic stroke patients beyond one year, who are most likely to be denied further therapy. Combined TMS and MRI — motor-evoked potentials in the affected limb with minimal fractional anisotropy asymmetry in the internal capsule — predicted potential for improvement up to three years after stroke.

Planning is goal setting. Immediate goals concern basic ADLs (sitting balance, transfers, toileting); later goals concern household, social, leisure and occupational activity. Three practical domains must be addressed: accommodation (where will the patient live and what adaptations are needed), personal support (what support exists and what extra help is essential), and life satisfaction (what roles will be fulfilled and how will time be occupied).

The two major problems in goal setting are failure to use a common language between professionals and with patients, and failure to agree a time frame. The goals of the hospital (early discharge), the patient (return to premorbid status) and the carer (minimise input, even at the cost of institutionalisation) frequently conflict; an essential team function is to identify and modify unrealistically high — and sometimes unjustifiably low — expectations.

Intervention: the minimum requirement is to maintain the status quo and prevent deterioration from poorly managed complications; beyond that, to facilitate recovery, minimise disability and prevent handicap. No rehabilitation technique has been shown to be superior to any other in physical therapy or in speech and language function, so a pragmatic functional approach individualised to each patient is recommended and rigid adherence to unproven theories should be discouraged.

Evaluation is confounded by spontaneous recovery, differing perceptions of a good outcome, and the profusion of instruments. ADL scales predominate because independence in ADLs determines care needs and resource use. Simple assessments used frequently are more useful than complex ones used rarely.

Early mobilisation is associated with good functional outcomes in observational and controlled studies, but review of pooled data found no unequivocal independent benefit; it is, however, not harmful to most stroke patients and contributes as part of routine stroke unit care to good long-term outcomes.

Motor recovery: balance and motor therapy with or without sensory feedback improves function and mobility; speed-dependent treadmill training benefits ambulant hemiparetic patients; robotic devices allow repetitive practice. Constraint-induced movement therapy (CIMT) prevents learned non-use; the EXCITE trial showed statistically significant and clinically relevant improvement in arm motor function persisting at least one year, but doubts remain about practicality and cost-effectiveness, and meta-analysis suggests benefit is proportional to the amount of exercise given to the affected limb, potentially achievable by conventional therapy.

Neuromuscular stimulation: peripheral electrostimulation improves functional motor ability, motor impairment and normality of movement. rTMS aids recovery of motor deficit, visuospatial neglect and aphasia — low-frequency stimulation over the unaffected hemisphere to restore inhibition, or high-frequency stimulation over the affected hemisphere to reactivate hypoactive regions.

Motor imagery / mental practice positively affects arm recovery and shows promise for the leg, with greater effect when combined with conventional rehabilitation in subacute patients; mirror therapy enhances lower-limb motor recovery.

Spatial neglect: the conceptual shift is from a spatial lack of awareness to a generalised reduction in attentional ability. Spatial techniques such as prism adaptation have limited success, whereas non-spatial attention training improves neglect with corresponding change in cortical activation. There is no effective treatment for apraxia — management focuses on early recognition, increasing awareness, and teaching adaptive skills and coping strategies. Complications, organisation and psychosocial care

Complications occur in about 60% of patients undergoing rehabilitation and are commoner with severe disability. Key problems are dysphagia (21–55% clinically, 44–78% on videofluoroscopy, with frequent silent aspiration; associated with higher mortality, longer stay and a three- to fivefold increase in institutionalisation at five years; videofluoroscopy is the gold standard and the water swallow test the practical bedside screen); dysphasia (comprehension is routinely overestimated); spasticity (botulinum toxin has replaced baclofen and dantrolene for focal spasticity — it reduces upper-limb tone but functional improvement is not established); the hemiplegic shoulder (subluxation in about one in five; pain from spasticity, subluxation, shoulder–hand syndrome or rotator cuff pathology, aggravated by careless handling; managed by positioning, avoiding traction on the arm and early passive movement); post-stroke depression (30–60%, pooled prevalence about 33%, higher in women, younger patients and those with greater disability, lasting seven to eight months untreated and correlating with failure to resume activities); plus central post-stroke pain, fatigue (no specific treatment shown to benefit), seizures, VTE, incontinence, pressure sores and falls with fractures on the hemiplegic side.

Organised (stroke unit) care both facilitates neurological recovery and expedites discharge. Audit shows patients spend over 50% of time in bed, 28% sitting out, only 13% in therapeutic activity, and are alone 60% of the therapeutic day; the CERISE study showed outcomes depend on therapy actually delivered rather than resources allocated. Caregiver training is a proven intervention. The reaction to stroke is akin to bereavement, and staff attitude matters — esteem plummets when patients are depersonalised as "CVAs" or "hemis". Organised, coordinated rehabilitation in partnership with patients and caregivers offers the only realistic hope of reducing disability and handicap after stroke.