In a stroke patient undergoing active rehabilitation who experiences a decline in motor function, what steps should be taken?

Management of Declining Motor Function During Active Stroke Rehabilitation

When a stroke patient experiences motor function decline during active rehabilitation, immediately investigate for new medical complications or recurrent stroke, then intensify targeted rehabilitation interventions regardless of time since stroke onset. 1

Immediate Assessment Priorities

Rule out acute medical deterioration first. Nurses and rehabilitation team members are typically the first to detect changes in motor status and must promptly communicate these observations to the medical team. 1 Screen for:

• New or recurrent stroke - Any decline in motor function warrants consideration of a new vascular event 1
• Medical complications - Assess for cardiac events, respiratory distress, infections, or metabolic derangements that commonly occur in stroke patients and can impair rehabilitation progress 1
• Cardiovascular status - Up to 75% of stroke survivors have concurrent cardiac disease, which may manifest as declining function during increased activity demands 1

Primary care providers should screen for ongoing physical issues including dysphagia, nutrition, hydration, continence, and pain, as these can directly impact motor performance. 1

Rehabilitation Response to Functional Decline

Post-stroke patients who experience a decline in functional status should receive targeted interventions, even if the decline occurs months or years post-stroke. 1 This is a Level B recommendation from the Canadian Stroke Best Practice guidelines.

Re-access Rehabilitation Services

Processes must be in place for stroke survivors to re-access rehabilitation services during longer-term recovery. 1 This may include:

• Physiatry consultation for comprehensive reassessment 1
• Physical therapy for motor retraining and strengthening 1
• Occupational therapy for activities of daily living and upper extremity function 1
• Speech-language pathology if communication or swallowing changes accompany motor decline 1

Intensify Task-Specific Practice

Task-specific practice (also called task-oriented or repetitive task practice) should be the foundation of motor rehabilitation. 1 This involves:

• Practice of whole tasks or pre-task movements for entire limbs or limb segments 1
• Functional activities including grasp, grip, trajectory movements to facilitate mobility and ADLs 1
• Upper and lower-limb movements, balance activities in sitting or standing, transfers, and functional mobility such as stairs or household ambulation 1

Evidence-Based Adjunctive Therapies

Mirror therapy is now recommended (weak for) for improvement in motor outcomes and ADLs. 1 In 2 systematic reviews of 62 RCTs (n=1982), mirror therapy provided statistically and clinically significant benefits for motor function, motor impairment, and ADLs. 1

Resistance training combined with task-specific practice is essential - passive recovery alone will not restore full function. 2 The protocol should include:

• Begin with low-intensity resistance at 40% of 1-repetition maximum with 10-15 repetitions 2
• Progress to moderate intensity (41-60% of 1-RM) with 8-10 repetitions as tolerated 2
• Perform resistance training 2-3 times per week to allow adequate recovery between sessions 2
• Implement static stretches held for 10-30 seconds with 3-4 repetitions 2

Functional electrical stimulation (FES) should be considered for patients with demonstrated impaired muscle contraction. 2 FES combined with biofeedback produces better results than standard physical therapy, FES, or biofeedback alone. 3

Aerobic Conditioning Component

Stroke rehabilitation serves as tertiary prevention - preventing complications of prolonged inactivity, decreasing recurrent stroke and cardiovascular events, and increasing aerobic fitness. 1, 4

Patients should perform moderate-intensity physical activity for 40 minutes per session, 3-4 times per week. 1, 4 This dual-purpose intervention:

• Improves motor function, gait velocity, and reduces energy cost of hemiparetic walking (tertiary prevention) 4
• Lowers cardiovascular risk factors including hypertension, glucose intolerance, and dyslipidemia (secondary prevention) 4

Critical Management Principles: What NOT to Do

Do not assume recovery has plateaued. Traditional beliefs that motor recovery ends within several months after stroke have been disproven - aggressive rehabilitation beyond this period increases aerobic capacity and sensorimotor function. 1

Do not use splinting in the recovery phase - it prevents restoration of normal movement and function. 2

Avoid relying on passive range of motion alone - active motor practice is essential for functional recovery. 2

Monitoring and Follow-Up

Recovery can fluctuate over time depending on degree of intact motor function, access to and consistent use of rehabilitation exercises, joint flexibility maintenance, pain management, and caregiver support for exercise adherence. 2

Periodic reassessment every 3-6 months is recommended to adjust the rehabilitation program based on functional gains. 2

Screen for depression and cognitive concerns as these commonly emerge during rehabilitation and directly impact motor recovery and participation in therapy. 1

Timeline Expectations

• Most motor recovery gains occur within the first 6 months, making this a critical window for intensive rehabilitation 2
• Rapid symptom relief typically occurs within 3-4 months with structured rehabilitation 2
• Optimal functional recovery requires 9-12 months of continued rehabilitation 2
• Restoration of ability to engage in physical activities extends beyond 4 months due to brain remodeling and adaptation of compensating strategies 2