Stroke rehabilitation

• personalized, multidisciplinary approach is crucial for optimal recovery
  • comprehensive rehabilitation program involves physical rehabilitation neuropsychologists, occupational therapists, speech-language pathologists, and other specialists
  • coordination with psychosocial support is crucial
• rehabilitation is a process that uses three major principles of recovery:
  • adaptation
  • restitution
  • neuroplasticity
• based on these principles, multiple approaches exist to enhance rehabilitation
• ongoing research continues to refine our understanding of neuroplasticity and develop novel rehabilitation strategies (incl. DBS, rTMS), offering hope for enhanced recovery in the future

Timing of stroke rehabilitation

Key components of stroke rehabilitation

Physical therapy

• physical therapy (PT) is a cornerstone of stroke rehabilitation, focusing on restoring motor function, improving physical abilities, balance, and relearning daily activities
• primary goals:
  • restore motor function
  • improve mobility and balance
  • prevent complications (e.g., contractures, muscle atrophy)
  • enhance overall physical independence
• initial assessment includes:
  • evaluation of muscle strength, tone, and range of motion
  • balance and gait analysis
  • functional mobility assessment
  • basic neurological examination
• interventions:
  • task-specific practice
  • gait training (treadmill, canes, walkers)
  • static and dynamic balance training
  • proprioceptive training
  • strength training (resistance exercises, functional strength training)
  • constraint-induced movement therapy (CIMT) – restraining the unaffected limb to promote use of the affected side
  • functional electrical stimulation (FES) to activate weak muscles
  • mirror therapy (Thieme, 2018)
    • mirror box therapy – when a stroke patient puts his weakened hand in the mirror box, and moves his strong hand, the mirror provides a reflection of the stronger hand, thus giving the illusion that movement is occurring in the hand affected by the stroke. Studies have shown an improvement in motor function and the rewiring of the brain
  • management of spasticity in collaboration with the medical team for pharmacological interventions
  • cardiovascular conditioning (aerobic exercise programs + endurance training)
  • pain management

Occupational therapy

• occupational therapy (OT) focuses on improving functional independence in activities of daily living and improving the quality of life for stroke survivors
• it is initiated early and continues through outpatient and community-based rehabilitation, with intensity based on individual needs and tolerance
• key areas of intervention include self-care activities, home management, work productivity, and leisure activities
• goals:
  • restore independence in self-care tasks
  • improve fine and gross motor functions
  • enhance cognitive functions
  • create a safe and accessible home (or work) environment
  • address emotional and social aspects of recovery
  • facilitate return to community roles and activities
• techniques:
  • paretic limb rehabilitation (such as mirror therapy or constraint-induced movement therapy)
  • cognitive training
  • sensory re-education (tactile stimulation, proprioceptive activities)
  • training patients in the use of adaptive equipment (orthoses, environmental modifications) and technology-assisted devices
  • social skills training
  • aphasia support- communication strategies and the use of augmentative and alternative communication (AAC) devices

Speech and language therapy

• addresses communication disorders (aphasia, dysarthria, speech apraxia) and swallowing difficulties that often occur post-stroke
• therapists focus on improving language comprehension, expression, and social communication skills
• techniques include:
  • activities to improve speaking, understanding, reading, and writing skills
  • strengthening muscles used for speech and improving articulation
  • apraxia therapy involves repetitive exercises to improve motor planning and speech production
  • voice therapy to regain control over voice quality, pitch, and volume
  • dysphagia therapy – exercises and techniques to improve swallowing safety and efficiency
• therapy should be individualized, targeting specific deficits and building the patient’s strengths
• regular assessment and adjustment of therapy plans ensure progress and adaptation to changing needs

Cognitive rehabilitation

• cognitive rehabilitation is a crucial component of the overall recovery process after a stroke
• it refers to a set of interventions designed to improve cognitive functions impaired by stroke, such as attention, memory, executive function (problem-solving), and other cognitive functions
• common cognitive deficits after stroke:
  • attention and concentration problems
  • memory impairment
  • executive function deficits (planning, problem-solving, decision-making)
  • language difficulties (aphasia)
  • visuospatial deficits
  • slowed information processing
• a comprehensive neuropsychological evaluation is needed to identify specific cognitive deficits, followed by ongoing assessment to track progress and adjust interventions
• approaches:
  • restorative approach aims to improve the impaired cognitive function through repetitive exercises (memory drills, attention training tasks)
  • compensatory and adaptive approach  – teaches strategies to work around cognitive deficits (such as using calendars for memory issues, breaking tasks into smaller steps, using reminder apps, simplifying home or work environments
• interventions:
  • computer-based cognitive training programs
  • paper-and-pencil exercises
  • group therapy sessions
  • real-life task practice
  • strategy training (e.g., mnemonics for memory)
  • virtual reality environments for cognitive training
  • brain-computer interfaces

→ Vascular cognitive impairment

Psychological support

• addresses the emotional challenges often experienced by stroke survivors, including depression, emotional lability, and anxiety
• psychological support:
  • improves overall recovery outcomes
  • enhances participation in rehabilitation
  • promotes better quality of life
  • helps in coping with lifestyle changes and disability
• non-pharmacological interventions:
  • psychotherapy
  • counseling (individual, family)
  • mindfulness and meditation
  • relaxation techniques
  • sexuality and intimacy counseling
• pharmacological interventions:
  • antidepressants (e.g., SSRIs)
  • anti-anxiety medications
  • mood stabilizers for emotional lability

Nutritional counseling

• ensures proper nutrition to support recovery and prevent complications

Novel techniques of stroke rehabilitation