What is the recommended physical medicine and rehabilitation (PM&R) approach for a patient who has suffered a stroke?

Physical Medicine and Rehabilitation Approach for Stroke Patients

Stroke rehabilitation should begin as early as possible once the patient is medically stable, with patients receiving at least three hours of direct task-specific therapy per day, five days a week, delivered by an interprofessional stroke team. 1

Initial Assessment and Timing

• All stroke patients should receive an initial assessment by rehabilitation professionals within 48 hours of admission 1
• Rehabilitation therapy should begin between 24-48 hours after stroke onset if there are no contraindications 1
• Very early mobilization (within 24 hours of stroke onset) is NOT recommended as it may be harmful 1
• Contraindications to early mobilization include:
  • Arterial puncture for interventional procedures
  • Unstable medical conditions
  • Low oxygen saturation
  • Lower limb fracture or injury 1

Rehabilitation Intensity and Setting

• Provide three hours per day of direct task-specific therapy, five days a week 1
• More intensive therapy results in better outcomes 1
• Rehabilitation should be delivered in a specialized stroke rehabilitation unit whenever possible 1
• The interprofessional rehabilitation team should include:
  • Physicians
  • Physiotherapists
  • Occupational therapists
  • Speech-language therapists
  • Nurses 1

Core Components of Stroke Rehabilitation

1. Mobilization and Physical Activity

• Frequent, brief, out-of-bed activity involving active sitting, standing, and walking should begin between 24-48 hours after stroke onset 1
• Early mobilization helps prevent complications such as:
  • Deep vein thrombosis
  • Skin breakdown
  • Contractures
  • Constipation
  • Pneumonia 1
• Adequate hydration should be encouraged to help prevent venous thromboembolism 1

2. Balance and Coordination Training

• Implement progressive challenge activities focusing on:
  • Static and dynamic balance exercises
  • Postural training with trunk support
  • Task-specific training with increasing difficulty 2
• Balance training is essential as ataxia is present in 68-86% of patients with brainstem/cerebellar stroke 2

3. Gait Rehabilitation

• Incorporate treadmill training with partial body weight support for patients with mild-to-moderate gait impairment 2
• Include specific gait components:
  • Gait speed training
  • Stair climbing practice
  • Turning exercises
  • Transfer training 2

4. Upper Extremity Rehabilitation

• For upper extremity dysfunction, constraint-induced movement therapy appears beneficial when started within two weeks after stroke 3, 4
• Include coordination activities with rhythmic auditory cueing for movement timing 2

5. Resistance and Aerobic Training

• Implement resistance training 2-3 days per week, with 1-3 sets of 10-15 repetitions of 8-10 exercises involving major muscle groups 2
• Incorporate aerobic exercise in the subacute period (11-78 days after stroke) to improve exercise capacity and walking endurance 1
• Exercise intensity should be tailored to the patient's condition:
  • 40-70% of heart rate reserve
  • 50-80% of maximal heart rate 1

Addressing Common Post-Stroke Complications

1. Dysphagia Management

• All stroke patients should receive standardized swallowing screening as early as possible, ideally on the day of admission 1
• Patients with dysphagia should receive specialized assessment and therapy 1

2. Temperature Management

• Monitor temperature as part of vital sign assessments every 4 hours for the first 48 hours 1
• For temperature >37.5°C, increase monitoring frequency, initiate temperature-reducing measures, and investigate possible infections 1

3. Seizure Management

• New-onset seizures should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limiting 1
• Prophylactic use of anticonvulsant medications is not recommended 1

4. Psychological Support

• Screen for and treat post-stroke depression, as it adversely affects recovery 5
• Consider selective serotonin reuptake inhibitors (SSRIs) which may benefit motor recovery beyond their antidepressant effect 5

Long-term Rehabilitation and Community Reintegration

• Rehabilitation should continue as long as the patient continues to achieve treatment goals, even after hospital discharge 2
• Ensure a smooth transition from inpatient to outpatient care with timely transfer of hospital discharge information 1
• Physical activity should be encouraged regardless of how much time has elapsed since stroke onset 1
• Family involvement early in the rehabilitation process improves adherence and outcomes 2

Monitoring Progress

• The interprofessional team should conduct at least one formal meeting per week to discuss patient progress, rehabilitation goals, and discharge arrangements 1
• Use standardized, valid assessment tools to evaluate stroke-related impairments and functional limitations 1
• Individualized rehabilitation plans should be regularly updated based on patient status 1

By following this comprehensive rehabilitation approach, stroke patients have the best chance of achieving optimal functional recovery, reducing mortality risk, and improving quality of life.