What is the recommended approach for rehabilitation after a stroke?

Rehabilitation of Stroke

Post-stroke patients should receive organized, coordinated multidisciplinary rehabilitation starting within 24-48 hours of medical stability, delivered at high intensity (at least 3 hours per day, 5-7 days per week) in a specialized stroke unit setting, as this approach significantly improves survival, functional independence, and return to home compared to standard care. 1, 2

Core Organizational Structure

Multidisciplinary team composition is essential and should include:

• Physician (rehabilitation specialist or stroke-experienced clinician) 1
• Physical therapist 1
• Occupational therapist 1
• Speech-language pathologist 1
• Nurse 1
• Psychologist 1
• Patient and family/caregivers as active team members 1

The rehabilitation setting must provide formally coordinated and organized care - outcomes data clearly demonstrate that organized stroke unit care results in better survival, greater independence, and higher rates of community discharge compared to unorganized services. 1

Timing and Intensity Parameters

Early initiation is critical:

• Begin rehabilitation within 24-48 hours after stroke onset once medical stability is achieved 2, 3
• Early mobilization prevents complications including deep vein thrombosis, pressure sores, contractures, constipation, and pneumonia 2
• Early bedside rehabilitation (within 48 hours) significantly improves activities of daily living, motor function, cognitive function, and quality of life 3

Intensity requirements are specific:

• Minimum 3 hours of therapy per day 2, 4
• Delivered 5-7 days per week 2, 4
• Sessions of 30-60 minutes duration are most effective 2
• This intensity applies across all multidisciplinary therapies combined (physical, occupational, speech) 4

Assessment Framework

Comprehensive functional assessment must be completed before discharge from acute care and should document: 1

• Activities of daily living (ADL) and instrumental ADL status 1
• Communication abilities 1
• Functional mobility 1
• Motor function using validated scales (Fugl-Meyer Assessment) 3
• Cognitive function (Montreal Cognitive Assessment) 3
• Balance and gait 1
• Muscle strength and range of motion 1

Prognostic assessment using NIHSS score guides rehabilitation planning:

• NIHSS >16 indicates high likelihood of death or severe disability 2, 5
• NIHSS <6 predicts good recovery 2, 5
• Even NIHSS score of zero can have significant motor impairments requiring rehabilitation 2

Treatment Components

Intensive, repetitive, task-specific motor practice is the foundation:

• All patients with gait limitations should receive intensive mobility-task training 1
• Upper extremity rehabilitation should involve repetitive functional task practice 1
• Constraint-induced movement therapy (modified for inpatient settings: 30 minutes graded task practice, 3 days per week, with 5-6 hours daily mitt wearing) shows superior motor function gains 1
• Progressive resistance training should target major muscle groups, 2-3 days per week, 1-3 sets of 10-15 repetitions 4

ADL training must be tailored to the anticipated discharge setting:

• All patients should receive ADL training specific to their individual needs 1
• Training should directly relate to the discharge living environment 1

Aerobic exercise prescription:

• Minimum 3 times weekly for at least 8 weeks 4
• Progress to 20+ minutes per session (excluding warm-up/cool-down) 4
• Target intensity: 40-70% heart rate reserve or 50-80% maximal heart rate 4

Speech and swallowing therapy:

• Patients with aphasia must receive speech-language therapy 1
• Dysphagia therapy should be offered at least 3 times weekly for as long as functional gains continue 4

Setting Selection Algorithm

For patients with moderate to severe stroke:

• Transfer to inpatient rehabilitation facility with organized stroke unit if not already in one 1
• If organized rehabilitation team unavailable, refer to facility with such team 1

For patients with mild stroke or those medically stable:

• Early supported discharge with intensive community-based therapy is equivalent to continued inpatient care when a multidisciplinary community team exists 1
• Outpatient rehabilitation must maintain organized team approach 1

Continuation and Follow-Up

Post-discharge monitoring is mandatory:

• Formal follow-up assessment of ADL, IADL, communication, and mobility within 30 days of discharge 1
• Long-term follow-up necessary as >30% of survivors report persistent participation restrictions at 4 years 2
• Most rapid recovery occurs in first 6 months, but chronic stroke patients continue to benefit from additional therapy 2

Community reintegration programs should include:

• Individualized exercise programs to improve cardiorespiratory fitness 2
• Group physical exercises, art, and music activities to improve quality of life 2

Common Pitfalls to Avoid

Insufficient therapy intensity - providing less than 3 hours daily across 5 days per week results in suboptimal recovery. 2, 4

Delayed rehabilitation initiation - waiting beyond 48 hours of medical stability misses the critical early recovery window. 2, 3

Uncoordinated care - rehabilitation delivered without formal team coordination and organization produces inferior outcomes compared to organized stroke unit care. 1

Premature discharge without community support - discharging patients without ensuring organized outpatient/home-based rehabilitation team availability compromises continued recovery. 1

Neglecting assessment of comorbidities - heart failure, chronic kidney disease, diabetes, and atrial fibrillation negatively affect recovery and must be actively managed. 5

Inadequate fatigue assessment - post-stroke fatigue is extremely common and limits participation; use standardized fatigue scales at early rehabilitation and 6-month review. 2, 4

Failure to address depression - post-stroke depression adversely affects recovery across multiple measures and requires treatment with psychotherapy or selective serotonin reuptake inhibitors. 2, 6