Comprehensive Evidence-Based Stroke Rehabilitation Program

Timing of Rehabilitation Initiation

Rehabilitation should begin as soon as medical stability is achieved, but avoid intensive mobilization within the first 24 hours post-stroke due to potential harm. 1, 2

Start range-of-motion exercises and physiologically sound position changes on the day of admission, progressing activity levels as medically tolerated 1
Delay intensive mobilization (out-of-bed activities >3 times daily) beyond 24 hours, as early trials showed increased mortality risk (OR 2.58) when started within 24 hours versus 48 hours 2, 3
Shorter, less frequent therapy sessions can be safely initiated within 24-48 hours after stroke 4
The most rapid recovery occurs in the first 6 months, but chronic stroke patients also benefit from continued therapy 5

Intensity and Frequency Standards

Provide at least 3 hours of multidisciplinary rehabilitation per day, at least 5 days per week, as this intensity is associated with superior functional outcomes. 6, 5

Intensive physical therapy (1-2 hours daily) produces better daily activity outcomes compared to standard practice (<45 minutes) 5
Continue therapy as much as "needed" to achieve optimal functional independence, not based on arbitrary time limits 1
Reassess function every 2-3 weeks to evaluate treatment effectiveness and adjust progression 7

Upper Extremity Rehabilitation

Task-Specific Training (Foundation)

Implement repetitive, challenging practice of functional, goal-oriented activities as the cornerstone of upper extremity rehabilitation. 1

Focus on repeated practice of specific functional tasks the patient needs to perform in daily life 1
Use trunk restraint during training to reduce compensatory movements and promote proximal control 1
Grade activities progressively to increase time the affected limb is used within functional tasks 7

Constraint-Induced Movement Therapy (CIMT)

CIMT is strongly recommended (Class I, Level A evidence) for patients with baseline ability to control wrist and finger extension, improving activity, participation, and quality of life. 1

Dosing protocols:

Original protocol: 3-6 hours/day for 5 days/week for 2 weeks 1
Modified protocol: 1 hour/day for 3 days/week for 10 weeks 1
Both protocols show efficacy; modified CIMT may be more practical for many settings 1

Strengthening Programs

Incorporate upper extremity strengthening as an adjunct to task-specific training when therapy time permits or activities can be performed outside formal sessions. 1

Perform 1-3 sets of 10-15 repetitions of 8-10 exercises involving major muscle groups 1
Schedule 2-3 days per week 1
Use higher repetitions (10-15) with reduced loads rather than 8-12 repetitions for safety 1

Stretching and Range of Motion

Perform stretching exercises 2-3 days per week before or after aerobic or strength training to increase ROM and prevent contractures. 1

Hold each stretch for 10-30 seconds 1
Focus on involved extremities to maintain joint mobility 1

Robotic Hand and Upper Extremity Devices

Robot-assisted movement training may be considered (Class IIb, Level A evidence) in combination with conventional therapy to improve motor function. 1

Evidence suggests potential benefit but is not as strong as for task-specific training or CIMT 1
Use as an adjunct to, not replacement for, conventional therapy 1
Particularly useful for providing high-repetition practice with objective feedback 1

Non-Invasive Brain Stimulation (NIBS)

Transcranial Direct Current Stimulation (tDCS) and Repetitive Transcranial Magnetic Stimulation (rTMS)

The effectiveness of non-invasive brain stimulation for motor recovery is not well established, with insufficient evidence for routine clinical use. 1, 2

Evidence in the acute period (first 2 weeks) remains scant and inconclusive 2
May be considered in research settings or specialized centers, but should not replace proven interventions 2
Current guidelines do not provide Class I recommendations for NIBS modalities 1

Functional Electrical Stimulation (FES)

Neuromuscular electrical stimulation (NMES) is reasonable to consider (Class IIa, Level A evidence) as an alternative to ankle-foot orthoses for foot drop and as an adjunct to task-specific upper extremity training. 1

NMES can provide short-term increases in motor strength and control for patients with impaired muscle contraction 7
Use as part of task-specific practice for upper extremity interventions 1
Consider for lower extremity foot drop when AFO is not tolerated or preferred 1

Lower Extremity and Gait Training

Core Mobility Training

Intensive, repetitive, mobility-task training is strongly recommended (Class I, Level A evidence) for all individuals with gait limitations after stroke. 1

Treadmill Training with Body-Weight Support

Practice walking with treadmill (with or without body-weight support) or overground walking combined with conventional rehabilitation may be reasonable (Class IIb, Level A evidence) for recovery of walking function. 1

Treadmill training allows patients to walk who might otherwise be unable to exercise 1
Body-weight support systems effectively decrease patient weight, enabling earlier gait training 1
Increasing treadmill grade while maintaining comfortable speed can augment intensity 1

Mechanically Assisted Walking and Robotic Devices

Mechanically assisted walking (treadmill, electromechanical gait trainer, robotic device) with body-weight support may be considered (Class IIb, Level A evidence) for patients who are nonambulatory or have low ambulatory ability early after stroke. 1

Use in combination with conventional therapy, not as standalone treatment 1
Particularly beneficial for patients unable to practice overground walking initially 1

Group Circuit Training

Group therapy with circuit training is a reasonable approach (Class IIa, Level A evidence) to improve walking. 1

Provides cost-effective, high-repetition practice 1
Enhances social engagement and motivation 1

Ankle-Foot Orthoses (AFO)

AFOs are strongly recommended (Class I, Level A evidence) for patients with remediable gait impairments (e.g., foot drop) to improve mobility, ankle and knee kinematics, kinetics, and energy cost of walking. 1, 7

Improves walking disability, step/stride length, and balance 7
Device prescription must be specific to patient needs, environment, and preferences 7

Cardiovascular Exercise and Conditioning

Incorporating cardiovascular exercise and strengthening interventions is reasonable (Class IIa, Level A evidence) for recovery of gait capacity and gait-related mobility tasks. 1

Aerobic training parameters: 1

Intensity: 40-70% peak oxygen uptake; 40-70% heart rate reserve; 50-80% maximal heart rate; RPE 11-14 (6-20 scale)
Frequency: 3-7 days/week
Duration: 20-60 minutes/session (or multiple 10-minute sessions)
Modalities: Large-muscle activities including walking, treadmill, stationary cycle, combined arm-leg ergometry, arm ergometry, seated stepper
Individually tailored aerobic training involving large muscle groups should be incorporated with monitoring of heart rate and blood pressure 7
Exercise is needed at least 3 times weekly for a minimum of 8 weeks, progressing to 20 minutes or more per session 7
After successful rehabilitation, offer individualized exercise programs to improve cardiorespiratory fitness 5

Mirror Therapy

Mirror therapy begun early after stroke shows promise for alleviation of neglect and may benefit motor recovery. 2

Particularly useful for patients with visuospatial neglect 2
Can be initiated within the first 2 weeks of stroke 2
Low-cost, low-risk intervention that can supplement other therapies 2

Virtual Reality and Gaming

Virtual reality may be beneficial (Class IIb, Level B evidence) for improvement of gait and can provide additional opportunities for engagement, feedback, repetition, and task-oriented training. 1, 7

Use as adjunct to conventional therapy 7
Provides motivating, game-based practice with objective feedback 7
Evidence stronger for upper extremity than lower extremity applications 1

Spasticity Management

Chemodenervation using botulinum toxin is recommended to increase range of motion and decrease pain for patients with focal symptomatically distressing spasticity in both upper and lower limbs. 7

Target specific muscle groups causing functional impairment or pain 7
Combine with stretching and functional training for optimal results 7
Reassess every 2-3 months for repeat injections as needed 7

Mental Practice and Cognitive Strategies

Mental practice should be considered as an adjunct for upper and lower limb motor retraining. 7

Employ anxiety management and distraction techniques when undertaking tasks to improve motor control 7
Use imagery and motor planning exercises alongside physical practice 7

Pharmacological Adjuncts

Selective Serotonin Reuptake Inhibitors (SSRIs)

The effectiveness of fluoxetine or other SSRIs to enhance motor recovery is not well established (Class IIb, Level B evidence), though they benefit motor recovery through mechanisms beyond antidepressant effects. 1, 4

SSRIs appear to have pleiotropic effects on neuroplasticity 4
Consider for patients with comorbid depression, where dual benefit may occur 4

Medications NOT Recommended

The use of dextroamphetamine or methylphenidate to facilitate motor recovery is not recommended (Class III, Level B evidence). 1

The effectiveness of levodopa to enhance motor recovery is not well established (Class IIb, Level B evidence). 1

Multidisciplinary Team Approach

Care in specialized stroke units with organized multidisciplinary teams significantly improves survival, functional status, and increases the number of patients returning home. 6, 5

Team composition should include: 1

Physical therapy
Occupational therapy
Speech-language pathology
Rehabilitation physician (physiatrist or stroke specialist)
Rehabilitation nursing
Kinesiotherapy (when available)

Team processes: 1

Reach shared decisions about rehabilitation programs with patient and family 1
Develop specific goals in consensus with patient, family, and team 1
Train family/caregivers to assist with functional activities 1
Provide interactive and written patient/caregiver education 1

Assessment and Outcome Measures

Use standardized assessment tools to document functional status and guide treatment planning. 1, 5

Key assessment tools: 1

NIHSS: Predicts recovery likelihood (>16 = poor prognosis; <6 = good recovery)
Functional Independence Measure (FIM): Documents functional status across multiple domains
Assess aerobic capacity, attention, cognition, balance, gait, motor function, muscle strength, pain, ROM, and self-care 5

Common Pitfalls and Caveats

Avoid very early intensive mobilization (<24 hours): The AVERT trial demonstrated potential harm from mobilizing patients within 24 hours, with increased mortality risk 2, 3
Don't delay all rehabilitation: While intensive mobilization should be delayed, gentle ROM exercises and positioning can begin immediately 1
Recognize that NIHSS of zero doesn't exclude rehabilitation needs: Even patients with zero NIHSS scores can have significant motor impairments requiring therapy 5
Address post-stroke fatigue systematically: Fatigue is very common and for some patients the most challenging problem; perform standardized fatigue assessment early and at 6-month review 6, 5
Screen for and treat depression: Post-stroke depression adversely affects recovery across multiple measures; psychotherapy and mindfulness-based therapy are recommended 5, 4
Prevent learned non-use: Engage patients in repetitive practice using normal movement patterns from the earliest appropriate time 7
Don't rely solely on neurophysiological approaches: The effectiveness of neurodevelopmental therapy and proprioceptive neuromuscular facilitation compared to other approaches is not established (Class IIb, Level B evidence) 1

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