Physical Medicine and Rehabilitation Clinics of North America
The Stroke Rehabilitation Paradigm
Section snippets
Stroke risk factors
The management of treatable risk factors that contribute to the development and progression of atherosclerotic cerebral vascular disease is important for reducing the risk of ischemic stroke. The major treatable risk factors for cerebral vascular atherosclerotic disease are similar to those for coronary atherosclerosis, including hypertension, cardiac disease, diabetes mellitus, smoking, dyslipidemia, and elevated fibrinogen levels. The risk increases in patients with two or more of these risk
Motor recovery
Motor recovery usually occurs in well-described patterns after stroke [38]. Within 48 hours of movement loss, muscle stretch reflexes become more active in the involved upper and lower extremity in a proximal to distal direction. The onset of spasticity results in resting postures that have been identified as synergy patterns for the upper and lower extremities. Volitional movement returns in the same pattern but eventually progresses to isolated movement. Spasticity decreases as volitional
Pharmacology
Pharmacologic interventions may help to facilitate motor recovery by allowing increased participation in therapy. Methylphenidate, a mild central nervous system stimulant whose mode of action is not well understood, may decrease depression and improve function in the early stages after stroke [82]. Available acetylcholinesterase inhibitors may aid learning of new information and procedural activities [83], [84]. Dopaminergic drugs, such as levodopa, and drugs that increase the availability of
Predicting disability and function status
Hemiparesis and motor recovery have been the most studied of all stroke impairments. Twitchell [38] described in detail a pattern of motor recovery after stroke. The severity of arm weakness at onset and the timing of the return of movement of the hand are important predictors of eventual motor recovery in the arm. The prognosis for return of useful hand function is poor when there is complete arm paralysis at onset or no measurable grasp strength by 4 weeks. Even among patients with severe arm
Motor improvements
Formal physiotherapy is often stopped when patients reach functional goals or progress too slowly to measure in a certain time frame. Unfortunately, some patients are discharged from therapy before a motor plateau is reached. Even then, a plateau in recovery does not necessarily imply a diminished capacity for further functional gains. Researchers have found that task-specific functional therapy for the arm leads to significant gains in motor control and strength if patients are allowed to
Discharge and additional therapy
Stroke survivors with traditional insurance plans or Medicare are more likely to be admitted to acute rehabilitation hospitals or units than patients with managed care [122]. Growing evidence indicates that intensity of rehabilitation correlates with outcome, which may potentially discriminate against patients with limited benefits. Overall, intensive stroke rehabilitation is associated with significantly lower mortality, institutionalization, and dependency [123].
In Europe, stroke survivors
Summary
There are new challenges to the existing paradigm of stroke rehabilitation, including defining dosage, standardizing treatment parameters across subjects and within treatment sessions, and determining what constitutes clinically significant treatment effects. Exercise type, intensity, duration, and physical location may shift in the future. The long-term goal is to develop prescriptive therapy programs in which specific activities are proven to treat specific motor system disorders. This may
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