Physiological Basis of Stroke Rehabilitation

Motor recovery usually occurs in well-described patterns after stroke. Within 48 hours of loss of movement, reflexes become more active in the involved arm and leg. As muscle tone returns, the arm and leg position themselves in resting postures known as synergy patterns.

• Arm flexor synergy: Shoulder flexion, adduction, internal rotation; elbow flexion; wrist flexion; finger flexion
• Arm extensor synergy: Shoulder, elbow, wrist, finger extension
• Leg flexor synergy: Hip flexion, adduction; knee flexion; ankle dorsiflexion
• Leg extensor synergy: Hip, knee extension; ankle plantar flexion

Voluntary movement may eventually return, and spasticity decreases with increased voluntary movement. However, muscle stretch reflexes always remain increased despite total recovery. Predictors for poor return of movement include absence of motion after 4 weeks.

Researchers are beginning to confirm the theories of motor recovery despite brain damage after stroke, which were first presented in the early 1980's. Plastic responses may occur in areas of the brain outside the damaged areas that result in partial return of lost function. Although findings such as these continue to support the need for rehabilitation services months or even years after a stroke occurs, these studies have small numbers of subjects. Large randomized clinical trials need to be completed in the future to convince the medical community that intensive rehabilitation interventions contribute to the improvement and maintenance of poststroke functional skills.

Goals of Stroke Rehabilitation

Several clinical trials have shown that rehabilitation should begin immediately after the stroke, as soon as the patient is medically stable. Basic goals of stroke rehabilitation include:

• Preventing recurrent stroke and secondary medical complications
• Avoiding medical complications such as deconditioning due to immobility and prolonged bed rest
• Encouraging self-care for the patient
• Teaching the patient to function as independently as possible in Activities of Daily Living through intensive therapy
• Providing guidance and emotional support to the family and caregiver
• Helping the patient and family reintegrate into the community

Guidelines for Stroke Rehabilitation

In 2003, the U.S. Department of Veterans Affairs Clinical Practice Guidelines Working Group published Management of Stroke Rehabilitation Care. To view the Guideline in its entirety, please click on the following link:

http://www.oqp.med.va.gov/cpg/STR/STR_base.htm

The American Heart Association and the American Stroke Association endorsed a Practice Guideline published in 2005 regarding management of adult stroke rehabilitation. To view the Guideline in its entirety, please click on the following link:

http://stroke.ahajournals.org/cgi/content/full/36/9/e100

Prevention of Secondary Stroke and Medical Complications

One of the first issues which must be immediately addressed in the stroke patient is early recurrence of stroke which occurs in up to 8% of stroke patients. Early recurrence of stroke together with progression of medical instability of a severe stroke account for 90% of deaths in the first week following stroke. Approximately 25% of deaths that occur in the first several years after stroke are due to recurrent stroke.