What is the recommended treatment for chronic stroke?

Treatment for Chronic Stroke

For chronic stroke patients (>6 months post-stroke), treatment should focus on intensive, task-specific rehabilitation therapy combined with aggressive secondary stroke prevention through antiplatelet therapy, blood pressure control, and lipid management. 1

Secondary Stroke Prevention

Antiplatelet Therapy

• Long-term single antiplatelet therapy with either aspirin 81 mg daily or clopidogrel 75 mg daily is the cornerstone of secondary prevention in chronic stroke patients. 1
• Clopidogrel demonstrated an 8.7% relative risk reduction compared to aspirin in preventing recurrent vascular events, though this benefit was most apparent in patients with peripheral arterial disease and less pronounced in stroke patients specifically. 2
• Dual antiplatelet therapy (DAPT) is NOT indicated in chronic stroke—it is only used acutely (21-30 days) for mild-moderate ischemic stroke or high-risk TIA. 1

Blood Pressure Management

• Target blood pressure should be <130/80 mmHg. 1
• Initiate angiotensin-converting enzyme inhibitors combined with a thiazide diuretic as first-line therapy, as this combination reduces stroke recurrence risk regardless of baseline hypertension diagnosis. 1
• Alternative acceptable agents include angiotensin II receptor blockers or thiazide diuretics alone; beta-blockers should be reserved for patients with concurrent ischemic heart disease. 1

Lipid Management

• Target LDL-cholesterol <1.8 mmol/L (70 mg/dL) for all chronic stroke patients, particularly those with atherosclerotic disease. 1
• Prescribe atorvastatin 80 mg daily for patients with LDL >2.5 mmol/L (100 mg/dL) without proven cardioembolic mechanism. 1
• Add ezetimibe if target LDL is not achieved with statin monotherapy; consider PCSK9 inhibitor referral for refractory cases. 1

Lifestyle Modifications

• Smoking cessation with counseling plus pharmacotherapy (nicotine replacement, bupropion, or varenicline) is mandatory. 1
• Prescribe low/moderate-intensity aerobic activity for 10 minutes, 4 days per week, or vigorous aerobic activity for 20 minutes twice weekly. 1
• Weight loss is required for overweight/obese patients (BMI assessment at every visit). 1
• Target HbA1c ≤7% for diabetic patients using glucose-lowering agents with demonstrated vascular benefit. 1

Rehabilitation Interventions

Rehabilitation Structure and Intensity

• Chronic stroke patients should receive intensive, task-specific therapy in a specialized stroke rehabilitation unit with an interdisciplinary team (physicians, nurses, physiotherapists, occupational therapists, speech-language therapists, social workers, dieticians). 1
• For chronic aphasia (>6 months post-stroke), provide at least 10 hours per week of therapist-led individual or group therapy for 3 weeks, plus 5+ hours per week of self-managed training. 1
• Physical rehabilitation should include 30-60 minutes per day, delivered 5-7 days per week, as this dose demonstrates significant benefit for functional recovery. 3

Functional Task Training

• Occupational therapy targeted toward activities of daily living improves performance scores (SMD 0.17) and reduces risk of deterioration or dependency (OR 0.71). 4
• Physical rehabilitation incorporating functional task training, regardless of specific historical approach (neurophysiological, motor learning, musculoskeletal), is effective—no single approach is superior to another. 3
• Rehabilitation should maximize scheduled task-specific therapy to meet optimal recovery and tolerability. 1

Communication Disorders

• For chronic aphasia, speech-language therapy improves functional communication, reading comprehension, expressive language, and written language. 1
• Include communication partner training for family members and caregivers to improve functional communication outcomes. 1
• Group therapy and conversation groups may supplement individual therapy intensity during hospitalization and serve as continuing therapy post-discharge. 1

Spasticity Management

• First-line treatment: antispastic positioning, range of motion exercises, stretching, splinting, and serial casting performed several times daily. 1, 5
• Second-line pharmacotherapy: For spasticity causing pain, poor skin hygiene, or decreased function, prescribe tizanidine, dantrolene, or oral baclofen (starting 5-10 mg/day, titrating to 30-80 mg/day divided into 3-4 doses). 1, 6
• Avoid benzodiazepines (diazepam) during stroke recovery due to deleterious effects on recovery and sedation. 5, 6
• For focal spasticity: Botulinum toxin injections are more effective than oral baclofen and should be used as first-line pharmacological intervention. 6, 7
• For severe, refractory spasticity unresponsive to oral medications, consider intrathecal baclofen (requires only 10% of systemic dose for equianalgesia). 7

Gait and Mobility Training

• Treadmill training with partial body weight support may be used as an adjunct to conventional therapy for patients with mild-to-moderate gait dysfunction. 1
• Commence mobilization within 48 hours of stroke onset unless contraindicated, but avoid intensive out-of-bed activities within the first 24 hours. 1

Shoulder Pain Management

• Address shoulder pain promptly as it occurs in up to 72% of stroke patients within the first year and can delay rehabilitation. 1
• Treatment options include positioning, range of motion exercises, modalities, and consideration of shoulder-hand pain syndrome in patients with combined motor, sensory, and visual-perceptual deficits. 1

Goal Setting and Monitoring

• Implement person-centered, collaborative goal setting with patients and families, clearly documented and regularly reviewed, including around transitions of care. 1
• Provide formal and informal patient, family, and caregiver education throughout the rehabilitation process. 1
• Reassess goals and plans at appropriate intervals over time, particularly for patients with communication disorders. 1

Common Pitfalls to Avoid

• Do not discontinue antiplatelet therapy without physician consultation—this significantly increases recurrent stroke risk (approximately 30% following initial stroke). 8
• Do not use dual antiplatelet therapy in chronic stroke patients—this is only indicated acutely for 21-30 days post-event. 1
• Do not prescribe omeprazole or esomeprazole with clopidogrel, as these significantly reduce antiplatelet activity; use alternative proton pump inhibitors if needed (dexlansoprazole, lansoprazole, pantoprazole). 2
• Do not limit rehabilitation to a single named approach—evidence shows no superiority of any specific method over another. 3
• Do not use oral baclofen as first-line for focal spasticity—botulinum toxin is more effective. 6, 7