• stroke is a leading cause of long-term disability worldwide
  • while full recovery isn’t always possible, a comprehensive rehabilitation program can help many stroke survivors regain function and improve their quality of life
  • the effectiveness of rehabilitation depends on:
    • severity and location of the stroke
    • timing of intervention (earlier is generally better)
    • intensity and duration of therapy
    • patient motivation and engagement
  • personalized, multidisciplinary approach is crucial for optimal recovery
    • comprehensive rehabilitation program involves physical rehabilitation neuropsychologists, occupational therapists, speech-language pathologists, and other specialists
    • coordination with psychosocial support is crucial
  • rehabilitation is a process that uses three major principles of recovery:
    • adaptation
    • restitution
    • neuroplasticity
  • based on these principles, multiple approaches exist to enhance rehabilitation
  • ongoing research continues to refine our understanding of neuroplasticity and develop novel rehabilitation strategies (incl. DBS, rTMS), offering hope for enhanced recovery in the future
Hemiparetic gait

Rehabilitation should be included in the complex care provided to stroke patients, where all other consequences of stroke are addressed

Timing of stroke rehabilitation

  • rehabilitation typically begins as soon as the patient is medically stable, often within 24-48 hours after the stroke
    • early intervention can significantly improve recovery outcomes
    • however, overly aggressive therapy in the first 24 hours is not beneficial (AVERT study) (AHA/ASA 2019 III/B-R)
  • the timing and intensity of rehabilitation in SAH and ICH must be individualized
  • rehabilitation may continue for months or even years after stroke

Key components of stroke rehabilitation

Physical therapy

  • physical therapy (PT) is a cornerstone of stroke rehabilitation, focusing on restoring motor function, improving physical abilities, balance, and relearning daily activities
  • primary goals:
    • restore motor function
    • improve mobility and balance
    • prevent complications (e.g., contractures, muscle atrophy)
    • enhance overall physical independence
  • initial assessment includes:
  • interventions:
    • task-specific practice
    • gait training (treadmill, canes, walkers)
    • static and dynamic balance training
    • proprioceptive training
    • strength training (resistance exercises, functional strength training)
    • constraint-induced movement therapy (CIMT) – restraining the unaffected limb to promote use of the affected side
    • functional electrical stimulation (FES) to activate weak muscles
    • mirror therapy (Thieme, 2018)
      • mirror box therapy – when a stroke patient puts his weakened hand in the mirror box, and moves his strong hand, the mirror provides a reflection of the stronger hand, thus giving the illusion that movement is occurring in the hand affected by the stroke. Studies have shown an improvement in motor function and the rewiring of the brain
    • management of spasticity in collaboration with the medical team for pharmacological interventions
    • cardiovascular conditioning (aerobic exercise programs + endurance training)
    • pain management

Occupational therapy

  • occupational therapy (OT) focuses on improving functional independence in activities of daily living and improving the quality of life for stroke survivors
  • it is initiated early and continues through outpatient and community-based rehabilitation, with intensity based on individual needs and tolerance
  • key areas of intervention include self-care activities, home management, work productivity, and leisure activities
  • goals:
    • restore independence in self-care tasks
    • improve fine and gross motor functions
    • enhance cognitive functions
    • create a safe and accessible home (or work) environment
    • address emotional and social aspects of recovery
    • facilitate return to community roles and activities
  • techniques:
    • paretic limb rehabilitation (such as mirror therapy or constraint-induced movement therapy)
    • cognitive training
    • sensory re-education (tactile stimulation, proprioceptive activities)
    • training patients in the use of adaptive equipment (orthoses, environmental modifications) and technology-assisted devices
    • social skills training
    • aphasia support- communication strategies and the use of augmentative and alternative communication (AAC) devices

Speech and language therapy

  • addresses communication disorders (aphasia, dysarthria, speech apraxia) and swallowing difficulties that often occur post-stroke
  • therapists focus on improving language comprehension, expression, and social communication skills
  • techniques include:
    • activities to improve speaking, understanding, reading, and writing skills
    • strengthening muscles used for speech and improving articulation
    • apraxia therapy involves repetitive exercises to improve motor planning and speech production
    • voice therapy to regain control over voice quality, pitch, and volume
    • dysphagia therapy – exercises and techniques to improve swallowing safety and efficiency
  • therapy should be individualized, targeting specific deficits and building the patient’s strengths
  • regular assessment and adjustment of therapy plans ensure progress and adaptation to changing needs

Cognitive rehabilitation

  • cognitive rehabilitation is a crucial component of the overall recovery process after a stroke
  • it refers to a set of interventions designed to improve cognitive functions impaired by stroke, such as attention, memory, executive function (problem-solving), and other cognitive functions
  • common cognitive deficits after stroke:
    • attention and concentration problems
    • memory impairment
    • executive function deficits (planning, problem-solving, decision-making)
    • language difficulties (aphasia)
    • visuospatial deficits
    • slowed information processing
  • a comprehensive neuropsychological evaluation is needed to identify specific cognitive deficits, followed by ongoing assessment to track progress and adjust interventions
  • approaches:
    • restorative approach aims to improve the impaired cognitive function through repetitive exercises (memory drills, attention training tasks)
    • compensatory and adaptive approach  – teaches strategies to work around cognitive deficits (such as using calendars for memory issues, breaking tasks into smaller steps, using reminder apps, simplifying home or work environments
  • interventions:
    • computer-based cognitive training programs
    • paper-and-pencil exercises
    • group therapy sessions
    • real-life task practice
    • strategy training (e.g., mnemonics for memory)
    • virtual reality environments for cognitive training
    • brain-computer interfaces

Psychological support

  • addresses the emotional challenges often experienced by stroke survivors, including depression, emotional lability, and anxiety
  • psychological support:
    • improves overall recovery outcomes
    • enhances participation in rehabilitation
    • promotes better quality of life
    • helps in coping with lifestyle changes and disability
  • non-pharmacological interventions:
    • psychotherapy
    • counseling (individual, family)
    • mindfulness and meditation
    • relaxation techniques
    • sexuality and intimacy counseling
  • pharmacological interventions:
    • antidepressants (e.g., SSRIs)
    • anti-anxiety medications
    • mood stabilizers for emotional lability

Nutritional counseling

  • ensures proper nutrition to support recovery and prevent complications

Novel techniques of stroke rehabilitation

  • virtual reality (VR) and gaming have emerged as innovative and promising tools in stroke rehabilitation, and some evidence suggests VR may be more effective than conventional therapy in certain aspects of rehabilitation
  • VR technologies provide immersive, interactive environments that can be used to practice motor skills, cognitive tasks, and activities of daily living in a controlled and safe setting
  • benefits:
    • increased engagement and motivation
    • ability to provide repetitive, task-specific practice
    • real-time feedback on performance
    • customizable difficulty levels
    • potential for remote rehabilitation
  • applications in stroke recovery
    • motor rehabilitation – upper limb function improvement, gait and balance training, fine motor skills practice
    • cognitive rehabilitation (memory, attention, and concentration)
    • training of activities of daily living (ADL)
  • VR and gaming should complement, not replace, traditional rehabilitation methods
  • robotic rehabilitation offers promising opportunities to enhance stroke recovery, particularly in providing intensive, repetitive, and task-specific movements, which are crucial for promoting neuroplasticity and motor recovery after a stroke
    • as technology advances and becomes more accessible, robotics is likely to play an increasingly important role in stroke rehabilitation programs
    • robotic therapy should complement, not replace, human therapist-led interventions and should be individualized based on patient needs and capabilities
  • robotic devices
    • upper limb robots
      • end-effector systems (e.g., MIT-MANUS, MIME)
      • exoskeleton systems (e.g., ARMin, InMotion ARM)
    • lower limb robots:
      • gait training robots (e.g., Lokomat, G-EO System)
      • ankle rehabilitation robots
    • hand and finger rehabilitation robots
  • advantages:
    • consistent, precise, and repetitive therapy
    • allow for high-intensity training sessions
    • offer objective measurement of patient progress
    • can be adjusted to the patient’s abilities and progress
    • may allow for semi-supervised or home-based therapy (telerehabilitation)
    • potential integration with virtual reality and AI for more engaging therapy
  • limitations:
    • high initial cost
    • need for technical expertise to operate and maintain
    • may not be suitable for all patients or all types of stroke-related impairments
  • large-scale, long-term studies to establish efficacy and cost-effectiveness
Robotic rehabilitation
Robotic rehabilitation
  • TMS is a non-invasive method of brain stimulation that uses magnetic fields to induce electric currents in specific brain regions, potentially modulating neural activity
    • enhances neuroplasticity, modulates cortical excitability, and promotes the formation of new neural connections
    • some studies show improvements in motor function, especially when combined with task-specific training
    • there is evidence for benefits in language recovery in aphasia
  • applications (currently mainly used in research settings)
  • protocols
    • high-frequency stimulation (>5 Hz) to increase cortical excitability
    • low-frequency stimulation (≤1 Hz) to decrease cortical excitability
  • common side effects include headache and scalp discomfort, and a  rare risk of seizures
  • not yet widely available or standardized in routine stroke care
  • DBS delivers constant electrical stimulation to a particular brain region through a surgically implanted electrode
  • it should modulate late-stage neuroplasticity for functional recovery
  • one of the targets in stroke patients is the dentate nucleus (Baker, 2023)

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Stroke rehabilitation
link: https://www.stroke-manual.com/stroke-rehabilitation/