From the Guidelines
Rehabilitation and medical management for stroke patients should begin as early as possible, ideally within 24-48 hours of stroke onset, and involve a multidisciplinary approach. This approach is supported by the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines, update 2015 1. Initial medical management includes antiplatelet therapy with aspirin (typically 81-325mg daily), often combined with clopidogrel (75mg daily) in the first 21 days for ischemic strokes, or blood pressure control for hemorrhagic strokes. Statins like atorvastatin (40-80mg daily) are recommended for most ischemic stroke patients.
Key Components of Rehabilitation
- Physical therapy focusing on mobility and strength training
- Occupational therapy for daily activities
- Speech therapy for communication and swallowing difficulties Rehabilitation intensity should be tailored to the patient's tolerance, typically 3-5 sessions weekly for each therapy type, lasting 45-60 minutes per session, as recommended by the management of adult stroke rehabilitation care guideline 1.
Blood Pressure Management and Secondary Prevention
Blood pressure management is crucial, targeting <130/80 mmHg with medications like ACE inhibitors or ARBs. Secondary prevention includes anticoagulation with direct oral anticoagulants (DOACs) like apixaban (5mg twice daily) for atrial fibrillation-related strokes.
Lifestyle Modifications
Lifestyle modifications including a Mediterranean diet, regular exercise, smoking cessation, and limiting alcohol consumption are essential components of long-term management. This comprehensive approach addresses both immediate recovery needs and reduces the risk of recurrent strokes by targeting underlying cardiovascular risk factors. The management of adult stroke rehabilitation care guideline also emphasizes the importance of a multidisciplinary team approach, including a physician, nurse, physical therapist, occupational therapist, and speech and language pathologist, to ensure consistency and reduce the risk of complications 1.
From the Research
Rehabilitation Strategies for Stroke Patients
Rehabilitation strategies for stroke patients are crucial for promoting recovery and improving functional outcomes. The following are some recommended rehabilitation strategies:
- Physical therapy interventions, such as sensory function impairments, motor learning programs, hemianopia and unilateral neglect, flexibility and joint integrity, strength training, hypertonicity, postural control, and gait training 2
- Occupational therapy interventions, including mirror therapy, task-oriented training, mental imagery, balance training, self-management strategies, and a multidisciplinary three-stages-of-care rehabilitation program 3
- Constraint-induced movement therapy, a rigorous program for upper extremity weakness, has been proven effective for improving arm function 4
- Repetitive transcranial magnetic stimulation, cellular management, robotic therapy, and pharmacologic strategies to enhance recovery are also areas of investigation 4
Medical Management Strategies for Stroke Patients
Medical management strategies for stroke patients are essential for preventing recurrence and promoting recovery. The following are some recommended medical management strategies:
- Anticoagulation for patients with atrial fibrillation 4
- Aggressive medical management for those with significant intracranial atherosclerosis 4
- Statin treatment for patients with atherosclerotic stroke and low-density lipoprotein cholesterol levels of 100 to 190 mg/dL 4
- Antiplatelet therapy for nonatrial fibrillation stroke 4
- Blood pressure reduction 4
- Management of poststroke depression, which can adversely affect recovery, using selective serotonin reuptake inhibitors (SSRIs) 4, 5
Key Principles of Recovery
Rehabilitation is a process that uses three major principles of recovery: adaptation, restitution, and neuroplasticity 5. A comprehensive rehabilitation program is essential to optimize poststroke outcomes, and successful rehabilitation involves understanding the natural history of stroke recovery and a multidisciplinary approach with judicious use of resources to identify and treat common poststroke sequelae 5.
Duration and Dose of Therapy
There is no defined duration of therapy for stroke patients, who may continue to experience recovery for several months after the event 4. The optimal amount or dose of therapy for stroke remains undetermined, as more intensive treatments have not been associated with better outcomes compared to standard intensities of therapy 6, 5. However, subgroup analysis revealed a significant difference based on dose of intervention, indicating that a dose of 30 to 60 minutes per day delivered five to seven days per week is effective 6.