Rehabilitation after stroke aims to preserve or improve range of motion, muscle strength, bowel and bladder function, and functional and cognitive abilities. Specific programs are based on the patient’s social situation (eg, prospects of returning to home or work), ability to participate in a rehabilitation program supervised by nurses and therapists, learning ability, motivation, and coping skills. A stroke that impairs comprehension often makes rehabilitation very difficult.
To prevent secondary disabilities (eg, contractures) and help prevent depression, rehabilitation should begin as soon as patients are medically stable. Preventive measures for pressure ulcers must be started even before patients are medically stable. Patients can safely begin sitting up once they are fully conscious and neurologic deficits are no longer progressing, usually ≤ 48 h after the stroke. Early in the rehabilitation period, when the affected extremities are flaccid, each joint is passively exercised through the normal range of motion (see Table 1: Rehabilitation: Normal Values for Range of Motion of Joints*) 3 to 4 times/day.
Regaining the ability to get out of bed and to transfer to a chair or wheelchair safely and independently is important for the patient’s psychologic and physical well-being. Ambulation problems, spasticity, visual field defects (eg, hemianopia), incoordination, and aphasia require specific therapy.
Hemiplegia: For patients with hemiplegia, placing 1 or 2 pillows under the affected arm can prevent dislocation of the shoulder. If the arm is flaccid, a well-constructed sling can prevent the weight of the arm and hand from overstretching the deltoid muscle and subluxating the shoulder. A posterior foot splint applied with the ankle in a 90° position can prevent equinus deformity (talipes equinus) and footdrop.
Resistive exercise for hemiplegic extremities may increase spasticity and thus is controversial. However, reeducation and coordination exercises of the affected extremities are added as soon as tolerated, often within 1 wk. Active and active-assistive range-of-motion exercises are started shortly afterward to maintain range of motion. Active exercise of the unaffected extremities must be encouraged, as long as it does not cause fatigue. Various activities of daily living (eg, moving in bed, turning, changing position, sitting up) should be practiced. For hemiplegic patients, the most important muscle for ambulation is the unaffected quadriceps. If weak, this muscle must be strengthened to assist the hemiplegic side.
A gait abnormality in hemiplegic patients is caused by many factors (eg, muscle weakness, spasticity, distorted body image) and is thus difficult to correct. Also, attempts to correct gait often increase spasticity, may result in muscle fatigue, and may increase the already high risk of falls, which often result in a hip fracture; functional prognosis of hemiplegic patients with a hip fracture is very poor. Consequently, as long as hemiplegic patients can walk safely and comfortably, gait correction should not be tried.
Novel treatments for hemiplegia include the following:
Constraint-induced movement therapy: The functional limb is restrained during waking hours, except during specific activities, and patients are forced to do tasks mainly with the affected extremity.
Robotic therapy: Robotic devices are used to provide intensive repetition of the therapeutic movement, guide an affected extremity in executing the movement, provide feedback (eg, on a computer screen) for patients, and measure patient progress.
Partial weight–supported ambulation: A device (eg, treadmill) that bears part of a patient’s weight is used during ambulation. The amount of weight borne and speed of ambulation can be adjusted. This approach is often used with robotics, which allows patients to contribute to ambulation but provides force as needed for ambulation.
Total body vibration: Patients stand on an exercise machine with a platform that vibrates by rapidly shifting weight from one foot to the other. The movement stimulates reflexive muscle contraction.
Ambulation problems: Before ambulation exercises can be started, patients must be able to stand. Patients first learn to stand from the sitting position. The height of the seat may need to be adjusted. Patients must stand with the hips and knees fully extended, leaning slightly forward and toward the unaffected side. Using the parallel bars is the safest way to practice standing.
The goal of ambulation exercises is to establish and maintain a safe gait, not to restore a normal gait. Most hemiplegic patients have a gait abnormality, which is caused by many factors (eg, muscle weakness, spasticity, distorted body image) and is thus difficult to correct. Also, attempts to correct gait often increase spasticity, may result in muscle fatigue, and may increase the already high risk of falls
During ambulation exercises, patients place the feet > 15 cm (6 in) apart and grasp the parallel bars with the unaffected hand. Patients take a shorter step with the hemiplegic leg and a longer step with the unaffected leg. Patients who begin walking without the parallel bars may need physical assistance from and later close supervision by the therapist. Generally, patients use a cane or walker when first walking without the parallel bars. The diameter of the cane handle should be large enough to accommodate an arthritic hand.
For stair-climbing, ascent starts with the better leg, and descent with the affected leg (good leads up; bad leads down). If possible, patients ascend and descend with the railing on the unaffected side, so that they can grasp the railing. Looking up the staircase may cause vertigo and should be avoided. During descent, patients should use a cane. The cane should be moved to the lower step shortly before descending with the bad leg.
Patients must learn to prevent falls, which are the most common accident among stroke patients and which often result in hip fracture. Usually, patients explain the fall by saying that their knees gave way. For hemiplegic patients, who almost always fall on their hemiplegic side, leaning their affected side against a railing (when standing or climbing stairs) can help prevent falls. Doing strengthening exercises for weak muscles, particularly in the trunk and legs, can also help.
For patients with symptomatic orthostatic hypotension, treatment includes support stockings, drugs, and tilt table training. Because hemiplegic patients are prone to vertigo, they should change body position slowly and take a moment after standing to establish equilibrium before walking. Comfortable, supportive shoes with rubber soles and with heels ≤ 2 cm (3/4 in) should be worn.
Spasticity: In some stroke patients, spasticity develops. Spasticity may be painful and debilitating. Slightly spastic knee extensors can lock the knee during standing or cause hyperextension (genu recurvatum), which may require a knee brace with an extension stop. Resistance applied to spastic plantar flexors causes ankle clonus; a short leg brace without a spring mechanism minimizes this problem.
Flexor spasticity develops in most hemiplegic hands and wrists. Unless patients with flexor spasticity do range-of-motion exercises several times a day, flexion contracture may develop rapidly, resulting in pain and difficulty maintaining personal hygiene. Patients and family members are taught to do these exercises, which are strongly encouraged. A hand or wrist splint may also be useful, particularly at night. One that is easy to apply and clean is best.
Heat or cold therapy can temporarily decrease spasticity and allow the muscle to be stretched. Hemiplegic patients may be given benzodiazepines to minimize apprehension and anxiety, particularly during the initial stage of rehabilitation, but not to reduce spasticity. The effectiveness of long-term benzodiazepine therapy for reducing spasticity is questionable. Methocarbamol
has limited value in relieving spasticity and causes sedation.
Hemianopia: Patients with hemianopia (defective vision or blindness in half the visual field of one or both eyes) should be made aware of it and taught to move their heads toward the hemiplegic side when scanning. Family members can help by placing important objects and by approaching the patient on the patient’s unaffected side. Repositioning the bed so that patients can see a person entering the room through the doorway may be useful. While walking, patients with hemianopia tend to bump into the door frame or obstacles on the hemiplegic side; they may need special training to avoid this problem.
When reading, patients who have difficulty looking to the left may benefit from drawing a red line on the left side of the newspaper column. When they reach the end of a line of text, they scan to the left of the column until they see the red line, cueing them to begin reading the next line. Using a rule to keep focused on each line of text may also help.
Occupational therapy: After a stroke, fine coordination may be absent, causing patients to become frustrated. Occupational therapists may need to modify patients’ activities and recommend assistive devices (see Table 4: Rehabilitation: Assistive Devices).
Occupational therapists should also evaluate the home for safety and determine the extent of social support. They can help obtain any necessary devices and equipment (eg, bathtub bench, grab bars by the bathtub or toilet). Occupational therapists can also recommend modifications that enable patients to do activities of daily living (ADLs) as safely and independently as possible—for example, rearranging the furniture in living areas and removing clutter. Patients and caretakers are taught how to transfer between surfaces (eg, shower, toilet, bed, chair) and, if necessary, how to modify ways of doing ADLs. For example, patients may be taught to dress or shave using only one hand and to eliminate unnecessary motion while preparing food or shopping for groceries. Therapists may suggest using clothing and shoes with touch fasteners (eg, Velcro) or dinner plates with rims and rubber grips (to facilitate handling). Patients with impairments in cognition and perception are taught ways to compensate. For example, they can use drug organizers (eg, containers marked for each day of the week)