From the Guidelines
Rehabilitation management for stroke should begin as early as possible, ideally within 24-48 hours of medical stability, with a comprehensive, multidisciplinary approach tailored to each patient's specific deficits and needs. This approach is supported by the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines, update 2015 1, which emphasizes the importance of early rehabilitation therapy, including physical, occupational, and speech therapy, to improve mobility, balance, strength, and activities of daily living.
The core components of stroke rehabilitation include:
- Physical therapy focusing on mobility, balance, and strength training
- Occupational therapy to improve activities of daily living
- Speech therapy for language, swallowing, and cognitive deficits
- Specific interventions such as constraint-induced movement therapy, functional electrical stimulation, and task-specific repetitive training
- Medications, including antispasticity agents like baclofen (10-25mg three times daily) or botulinum toxin injections for severe spasticity, and SSRIs like sertraline (50-200mg daily) for depression
Rehabilitation intensity matters, with patients typically benefiting from 3 hours per day of direct task-specific therapy, five days a week, delivered by the interprofessional stroke team 1. Adaptive equipment, such as walkers, canes, or communication devices, may be necessary to support rehabilitation. Family education and involvement are crucial for successful rehabilitation, and recovery follows a predictable pattern with most improvement occurring in the first 3-6 months, though gains can continue for years with persistent therapy 1. The neuroplasticity of the brain is the biological basis for recovery and is enhanced through intensive, repetitive, and task-specific rehabilitation exercises.
The interprofessional rehabilitation team should assess patients within 48 hours of admission and develop a comprehensive individualized rehabilitation plan, which reflects the severity of the stroke and the needs and goals of the patient, the best available research evidence, and clinical judgment 1. The team should promote the practice and transfer of skills gained in therapy into the patient’s daily routine and in the community, and provide opportunities for patients to repeat rehabilitation techniques learned in therapy and implement them while supervised by stroke rehabilitation nurses 1.
From the Research
Rehabilitation Management for Stroke
The rehabilitation management for stroke involves a comprehensive and multidisciplinary approach to optimize post-stroke outcomes. Key aspects of rehabilitation management include:
- A comprehensive rehabilitation program that uses three major principles of recovery: adaptation, restitution, and neuroplasticity 2
- Multiple different approaches, both pharmacologic and nonpharmacologic, to enhance rehabilitation 2
- Involvement of a variety of health care professionals, including neurologists, in stroke rehabilitation 2, 3
- Understanding the natural history of stroke recovery and a multidisciplinary approach with judicious use of resources to identify and treat common post-stroke sequelae 2
Timing of Rehabilitation
The optimal timing of rehabilitation after stroke is still unclear, with some studies suggesting that commencing physical rehabilitation within 24 hours of stroke may not provide clear benefits 4. However, other studies suggest that earlier transfer to rehabilitation services may provide better functional outcomes 4. Rehabilitation nursing should focus on goals, outcomes, and the attainment or maintenance of functional capacity, understanding long-range patient needs, and wellness 3.
Approaches to Physical Rehabilitation
Various approaches to physical rehabilitation are used after stroke, including functional task training and neurophysiological approaches. Functional task training may improve independence in activities of daily living (IADL) and motor function 5. Neurophysiological approaches may be less effective than other approaches in improving IADL and motor function 5. Additional physical rehabilitation may provide added benefits, including improved IADL, motor function, balance, and gait velocity 5.
Components of Rehabilitation
Rehabilitation interventions should be incorporated into care protocols for all patients and should begin immediately 6. During the initial phases of care, rehabilitation interventions are mostly passive and emphasize prevention of secondary co-impairments such as contractures, pressure ulcers, and deconditioning 6. As the patient becomes stable, more intensive therapy can be initiated in preparation for transition into the post-acute phase of active rehabilitation 6.