What are the ways to improve neurological recovery after a stroke?

Improving Neurological Recovery After Stroke

The most effective ways to improve neurological recovery after stroke include admission to a specialized stroke unit, early intensive rehabilitation therapy, avoidance of medications that impair recovery (particularly benzodiazepines, neuroleptics, and certain antihypertensives), and consideration of selective serotonin reuptake inhibitors (SSRIs) for motor recovery enhancement. 1

Specialized Stroke Unit Care

Admission to a comprehensive stroke unit is one of the most evidence-based interventions for improving neurological outcomes and should be implemented as soon as medically stable. 1, 2, 3

• Stroke unit care demonstrates benefits comparable to intravenous thrombolytic therapy in reducing mortality and morbidity, with effects persisting for years 1
• These units provide geographically defined facilities staffed by specialized physicians, nurses, and rehabilitation personnel with monitoring capabilities 1
• The benefit applies broadly regardless of stroke severity or time from onset, making it accessible to patients who cannot receive thrombolytic therapy 1

Early Rehabilitation Interventions

Intensive, task-specific rehabilitation should begin as early as medically possible, with evidence supporting daily therapy even starting at 3 days post-stroke for patients with moderate to severe deficits. 1, 3

Motor Recovery Strategies

• Lower extremity strengthening and resistance training improve gait speed and functional outcomes when provided to community-dwelling individuals beyond 6 months post-stroke 1
• Neuromuscular electrical stimulation (NMES) applied to ankle dorsiflexors during gait produces small but significant improvements in walking capacity, with effects equivalent to ankle-foot orthoses 1
• Rhythmic auditory cueing synchronized with overground walking improves velocity and stride length 1
• Acupuncture as an adjunct to standard rehabilitation may improve walking mobility, though should not replace conventional therapy 1

Cognitive and Sensory Interventions

• For hemispatial neglect, repeated interventions including prism adaptation, visual scanning training, limb activation, and mental imagery combined approaches are reasonable 1
• Standardized assessment of somatosensory function should guide rehabilitation planning 2, 3
• Touch discrimination training may benefit patients with somatosensory loss 3
• Cognitive retraining should be provided for attention deficits 3

Communication Disorders

• Daily aphasia therapy improves communication outcomes in moderate to severe aphasia, with intensive treatment favored though no consensus exists on optimal duration 1
• Speech and language pathologists should evaluate all stroke patients for communication difficulties 3
• Computer-based therapy and group therapy approaches show efficacy, with treatment remaining effective even in chronic stages (>6 months post-stroke) 1

Pharmacological Considerations

Medications to Avoid

Certain medications demonstrably impair stroke recovery and should be avoided or used with extreme caution. 1

• Neuroleptics, benzodiazepines, phenobarbital, and phenytoin should not be used during stroke recovery unless absolutely necessary, as they impair neurological outcomes 1
• Centrally acting α2-adrenergic receptor agonists (clonidine) and α1-receptor antagonists (prazosin) as antihypertensives are associated with poorer recovery outcomes 1
• Alternative antihypertensive classes (ACE inhibitors, angiotensin receptor blockers) should be preferentially selected 1

Medications That May Enhance Recovery

Selective serotonin reuptake inhibitors (SSRIs), particularly fluoxetine, show promise for motor recovery enhancement, though larger trials are ongoing. 1

• A double-blind, placebo-controlled trial demonstrated fluoxetine improved motor recovery 1
• A systematic review and meta-analysis found evidence of benefit for SSRIs in overall disability after stroke 1
• The quality of existing studies is not yet sufficient for definitive recommendation, but consideration in selected patients is reasonable 1

CNS stimulants and neurotransmitter-releasing agents may be considered in selected patients to improve rehabilitation participation or enhance motor recovery, though evidence remains insufficient for routine use. 1

• Dextroamphetamine has been tested at 10 mg per day with inconsistent findings and carries cardiovascular risks 1
• Levodopa showed short-term motor benefit but was limited by small sample size and baseline differences 1
• Insufficient evidence exists regarding optimal dosing and safety for routine clinical use 1

Prevention of Complications

Early mobilization and complication prevention are critical for optimizing recovery. 2, 3

• Implement early mobilization as tolerated to prevent deep vein thrombosis, pulmonary embolism, and pressure sores 2
• Use intermittent external compression stockings for DVT prophylaxis 2
• Perform swallowing assessment before oral intake to prevent aspiration 2
• Monitor for and promptly treat infections, particularly pneumonia and urinary tract infections 2
• Assess for seizures but avoid prophylactic anticonvulsants 2

Discharge Planning and Long-Term Support

Comprehensive discharge planning with family education and community resource connection improves long-term outcomes. 1

• Patients, families, and caregivers should be fully informed and involved in all aspects of healthcare and safety needs 1
• Families require equipment and training in safe patient handling and positioning 1
• Vocational counseling should be offered when appropriate for patients who worked before stroke 1
• Leisure activities should be identified, encouraged, and facilitated 1
• Case management should be implemented for complex situations 1
• Hospitals should maintain current inventories of community resources and assist patients in accessing services 1

Common Pitfalls to Avoid

• Do not use overhead pulley exercises for shoulder rehabilitation, as they are not recommended and may cause harm 3
• Avoid glucose-containing intravenous solutions in the acute phase, as hyperglycemia worsens outcomes 1
• Do not delay rehabilitation waiting for "spontaneous recovery"—early intensive therapy produces superior outcomes 1
• Avoid assuming that chronic stroke patients (>6 months) cannot benefit from therapy; evidence supports continued efficacy in chronic stages 1