Physical Therapy in Post-Stroke Care is Tertiary Prevention
Physical therapy in a post-stroke patient receiving rehabilitation and disease prevention measures represents tertiary prevention. 1
Why This is Tertiary Prevention
The American Heart Association explicitly classifies post-stroke physical therapy and rehabilitation as tertiary prevention because it targets patients who already have established disability after a stroke. 1 This classification is based on the fundamental principle that tertiary prevention aims to:
- Prevent complications of prolonged inactivity (contractures, deconditioning, pneumonia, deep vein thrombosis) 1, 2
- Decrease recurrent stroke and other cardiovascular events through aerobic conditioning 1, 3
- Increase aerobic fitness and functional recovery in stroke survivors with residual weakness 1
- Restore motor function and maximize independence in activities of daily living despite permanent neurological injury 1, 2
Understanding the Distinction from Other Prevention Levels
Secondary prevention addresses risk factors to prevent a second stroke before it occurs—this includes blood pressure control, antiplatelet therapy, lipid management, and diabetes control. 3 While stroke rehabilitation programs incorporate these secondary prevention measures (patients should participate in secondary prevention programs per guidelines), the rehabilitation itself is fundamentally tertiary because it addresses existing disability. 3
Primary prevention would apply to someone who has never had a stroke and is working to prevent the first event through risk factor modification. 1
The Dual Role of Post-Stroke Rehabilitation
Post-stroke physical therapy serves a dual function that can create confusion:
Primary tertiary function: Restoring motor function, improving gait velocity, reducing energy cost of hemiparetic walking, and maximizing independence despite permanent neurological injury 1, 2
Embedded secondary function: Aerobic conditioning within the rehabilitation program lowers cardiovascular risk factors (hypertension, glucose intolerance, dyslipidemia), thereby contributing to secondary stroke prevention while the patient is undergoing tertiary care 1, 3
The American Heart Association emphasizes that the post-stroke period is a critical window to implement secondary prevention interventions, but these are delivered as part of the overall tertiary rehabilitation program. 1
Recommended Exercise Prescription (Tertiary Prevention Framework)
Stroke survivors should perform moderate-intensity physical activity for about 40 minutes per session, 3–4 times per week; this regimen supports both functional restoration (tertiary) and cardiovascular risk reduction (secondary). 1, 3 More specifically:
- Aerobic training: 40-70% heart rate reserve, 20-60 minutes per session, 3-7 days per week 3, 4
- Resistance training: 1-3 sets of 10-15 repetitions of 8-10 exercises involving major muscle groups, 2-3 days per week 3, 4
- Flexibility exercises: 2-3 days per week, holding each stretch 10-30 seconds to prevent contractures 3, 4
- Neuromuscular training: Coordination and balance activities 2-3 days per week to improve safety during activities of daily living 3, 4
Common Pitfall to Avoid
Do not confuse the secondary prevention components embedded within stroke rehabilitation (exercise reducing cardiovascular risk) with the overall classification of the intervention. The rehabilitation program as a whole is tertiary prevention because it addresses established disability and aims to restore function in someone who has already experienced the disease event. 1, 2