Grand Rounds
Elliot J. Roth, MD, Editor

The Rehabilitation of Patients Recovering
from Brainstem Strokes: Case Studies and
Clinical Considerations
Elizabeth Kruger, Robert Teasell, Katherine Salter, Norine Foley, and Chelsea Hellings

An estimated 15% of all patients admitted to stroke rehabilitation units experience a brainstem stroke. Two case studies are
presented to illustrate some of the difficulties encountered in the rehabilitation of these individuals. Unlike hemispheric
stroke, the characteristic consequences of brainstem stroke include ataxia, dysarthria, and diplopia. Additionally,
individuals with brainstem stroke may suffer from severe dysphagia and may require enteral feedings. Unlike the
rehabilitation of patients with hemispheric stroke, where there is an impressive and relatively comprehensive research
literature, there has been surprisingly little research published on the rehabilitation of patients with brainstem stroke
despite the fact they represent a significant number of patients admitted to stroke rehabilitation units. Key words: ataxia,
brainstem stroke, diplopia, dysarthria, dysphagia, paresis, rehabilitation

L

esions affecting the brainstem region
account for up to 25% of all strokes.1
Typically brainstem strokes are a
consequence of an infarction occurring in the
territories of the basilar or vertebral arteries,2
although a significant percentage are hemorrhagic
in etiology. The brainstem plays an essential role in
controlling balance, coordination, hearing,
speech, eye movements, and swallowing; hence,
patients who have sustained brainstem strokes
often suffer from ataxia and dysphagia, while a
lesser number may experience hemiparesis,
diplopia, and dysarthria.3 Signs of cortical
involvement such as neglect, visual-perceptual
disorders, aphasia, and apraxias are generally
absent as hemispheric cortical and subcortical
areas are spared.
Chua and Kong2 reported that the prognosis for
functional recovery and long-term survival in individuals with brainstem stroke was better than that
of individuals with hemispheric stroke. Similarly,
Turney et al.4 reported 35% of brainstem infarction survivors returned to living independently
within the first year after stroke onset, whereas
only 22% of hemispheric stroke survivors
achieved independent living within the first year
poststroke. Given that blood supply to the

56

brainstem region is provided via the multiple tiny
blood vessels arising directly from the
vertebrobasilar arteries, brainstem strokes are often small.5 Generally, there is no involvement of
Elizabeth Kruger, (BMSc student), is Research Associate,
Aging, Rehabilitation and Geriatric Care Program, Lawson
Health Research Institute, London, Ontario, Canada.
Robert Teasell, MD, FRCPC, is Professor and Chair-Chief,
Department of Physical Medicine and Rehabilitation, St. Joseph’s
Health Care and the Schulich School of Medicine and Dentistry,
University of Western Ontario, London, Ontario, and Aging,
Rehabilitation and Geriatric Care Program, Lawson Health
Research Institute, London, Ontario, Canada.
Katherine Salter, BA (psychology), is Research Associate,
Aging, Rehabilitation and Geriatric Care Program, Lawson
Health Research Institute, London, Ontario, Canada.
Norine Foley, MSc (epidemiology), is Research Associate, Aging,
Rehabilitation and Geriatric Care Program, Lawson Health
Research Institute, London, Ontario, Canada.
Chelsea Hellings, BSc (psychology), is Research Associate,
Aging, Rehabilitation and Geriatric Care Program, Lawson
Health Research Institute, London, Ontario, Canada.
Top Stroke Rehabil 2007;14(5):56–64
© 2007 Thomas Land Publishers, Inc.
www.thomasland.com
doi: 10.1310/tsr1405-56

Rehabilitation of Brainstem Stroke Patients

cortical or subcortical structures, thereby improving rehabilitation prognosis for the individual with
brainstem stroke.
Teasell et al.3 reported that among a cohort of
565 stroke patients admitted to a stroke rehabilitation unit, a substantial percentage (15%) suffered
from a brainstem stroke. Despite the relative frequency with which brainstem strokes occur, and
their considerable representation on rehabilitation
units, there is surprisingly little written about the
rehabilitation of these patients. In this report, we
present two cases of individuals who suffered from
a brainstem stroke and then discuss rehabilitation
issues specific to brainstem stroke patients.
Case Study 1
A 35-year-old man experienced a left-sided cerebellar and pontine infarct. Two days following the
incident, he underwent a left occipital craniotomy
after developing a cerebellar hemorrhage. Clinical
presentation included right hemisensory loss, severe left-sided ataxia, dysarthria, diplopia, urinary
retention, extreme paresis, fatigue, and some
memory loss. Initially, he was treated at an acute
care hospital and, after 3 weeks, was transferred to
a rehabilitation facility. He remained a patient in
the rehabilitation facility for a little over 3 months
and returned home following discharge. The etiology of his initial stroke was never established. Prior
to the initial stroke event, the patient lived at home
with his wife and children in a rural community.
His medical history appeared to be noncontributory to the stroke event. He was normotensive with
normal serum cholesterol levels, and no history of
diabetic or cardiac disease.
During inpatient rehabilitation, he made slow
but steady improvements. His mobility was hindered by severe left-sided ataxia and right
hemisensory loss. Initially, he was unable to sit on
the side of the bed without immediately falling to
the left. He underwent standard physiotherapy exercises designed to improve sensation, range of
motion, postural control, mobility, balance, transfers, stair climbing, and locomotion. Occupational
therapists provided functional mobility training,
self-care retraining, and assessments of his upper

57

extremity function, cognition and perception,
community living skills, and ability to drive and
return to work. The speech language pathologist
initially placed him on a soft solids and thin fluids
diet after assessing his swallowing and ataxic dysarthria. He received oral motor exercises as well as
dysarthria therapy beginning at a single-word level
and progressing to the level of reading out loud.
By discharge, the patient was able to ambulate
slowly with a cane and was independent in activities of daily living (ADLs). His urinary retention
resolved. Dysarthria improved in both vocal quality and pitch through therapy. He experienced
some mood swings due to frustration with his
disability; however, his mood improved as his
functional abilities improved. He continued to experience diminished balance, decreased coordination on the left side, right-sided sensory deficits
and numbness, fatigue, and weight gain.
Approximately 1.5 years poststroke, he was able
to return to his place of work with return to fulltime hours, following a graduated return-to-work
schedule. Significant ergonomic adjustments to his
office were required. A vocational therapist monitored his progress throughout the work trial. On
review at 1 year, he remained, successfully, at
work.
Case Study 2
The second case was a 32-year-old married
woman working full-time. She was admitted to
hospital with sudden onset of right vertebral artery
and basilar artery occlusion. MRI demonstrated
right thalamic, right pontine, and left cerebellar
infarcts (Figures 1 and 2). She required intubation
with subsequent tracheostomy, an ICU stay, and a
feeding tube for demonstrated aspiration on modified barium swallow examination (Figure 3). Initial problems included a spastic left hemiparesis,
left-sided ataxia, dysarthria, dysphagia, diplopia,
and emotional lability. She was in acute care for 6
weeks and on the rehabilitation unit for 18 weeks.
Significant gains were made during the 18
weeks she was on the inpatient rehabilitation unit
(Table 1). Her physiotherapy incorporated activities such as postural correction, trunk and pelvis

58

(1)

TOPICS IN STROKE REHABILITATION/SEPT-OCT 2007

(2)

Figures 1 and 2. MRI demonstrates infarcts involving the left cerebellum, right thalamus, and right
hemipons (case 2).

Figure 3. Videofluoroscopic modified barium swallowing tests study of 31-year-old female demonstrating laryngeal penetration and aspiration of thin fluids.

Rehabilitation of Brainstem Stroke Patients

59

Table 1. Test results for case study 2

Timed Up and Go
2-Minute Walk Test
Greatest distances walked before
requiring a rest
Time to walk greatest distance
Berg Balance Score
COVS

Admission

Discharge

Nonambulatory
Nonambulatory
Nonambulatory

Not tested
46 meters
81 meters

Nonambulatory
2/56
22/91

3 minutes, 38 seconds
32/56
63/91

Stages of motor recovery (Chedoke-McMaster Stroke Assessment Score)a
Arm
Hand
Leg
Foot
Postural control

2
2
3
3
2

4
5
5
5
5

Note: COVS = Clinical Outcome Variables Scale.
a
The Chedoke-McMaster Stroke Assessment provides a means by which to classify
patients according to stage of motor recovery. Each dimension is rated on a 7-point scale that
corresponds to Brunnstrom’s seven stages of motor recovery.39

activation, sitting and standing balance activities,
shoulder mobilization and elongation into external
rotation-reaching, scapular mobility, stability exercises, ambulation, and stair climbing. She received
standard occupational therapy exercises and assessments. Her speech therapy was focused on improving her breath support, working at the word level at
the reduced rate of speech, and contractive stress at
the two-word level. Attempts to improve her conversational speech were made using tasks requiring
her to either increase or lower her pitch and develop
greater inflection in her voice.
At the time of discharge, the patient was able to
ambulate with a rollator walker and one-person
assist. She was independent for ADLs. The combination of ataxia and hemiparesis presented some
special challenges. At time of follow-up 6 months
later, she was regularly exercising, walking with a
cane, and optimistic she would eventually be able
to return to work.
Discussion
It is well known that patients with brainstem
stroke are a heterogeneous group in terms of
pathophysiology, symptomatology, and prognosis.2 Common problems following a brainstem

stroke include dysphagia/aspiration, ataxia, dysarthria, paresis, and diplopia in a number of combinations (Table 2). Our first patient suffered from
ataxia, dysarthria, and diplopia but was spared
dysphagia and paresis. Our second patient experienced more of the spectrum of sequelae common
to brainstem stroke.
Dysphagia

Dysphagia, a common consequence of
brainstem stroke, is typically associated with a
greater likelihood of occurrence when compared

Table 2. Clinical impairments in brainstem patients
Impairment

Number of brainstem patients (N = 85)

Dysphagia
Ataxia
Dysarthria
Paresis
Diplopia

40 (47%)
73 (86%)
42 (49%)
41 (48%)
32 (38%)

Adapted from Teasell R, Foley N, Doherty T, Finestone H. Clinical
characteristics of patients with brainstem stroke admitted to a rehabilitation unit. Arch Phys Med Rehabil. 2002;83:1013–1016. Copyright © 2002 by Elsevier.

60

TOPICS IN STROKE REHABILITATION/SEPT-OCT 2007

Table 3. Incidence of aspiration confirmed by VMBS
among hemispheric and brainstem stroke patients
admitted to stroke rehabilitation unit
Lesion location
Total pts
Pts with VMBS
Pts with aspiration on VMBS
Pts with aspiration on VMBS (%)
Aspiration of total stroke (%)

All hemispheres

Brainstem

192
28
21
75
10.9

38
18
15
83
39.5

Note: Patients were evaluated by videofluoroscopic modified
barium-swallowing (VMBS) if they were suspected of experiencing
sufficient swallowing difficulties to place them at risk for aspiration.
Swallowing difficulties were suspected in individuals with the following: choking with oral feeds, dysarthria, or wet-hoarse vocal quality.
Pts = patients.
Adapted from Teasell RW, Bach D, McRae M. Prevalence and
recovery of aspiration poststroke: a retrospective analysis. Dysphagia.
1994;9:35–39. Copyright © 1994 by Springer.

with hemispheric strokes.6 However, there are few
studies reporting the incidence of dysphagia in
brainstem stroke patients. Teasell et al.3 reported
that 40/85 (47%) of the patients with brainstem
stroke admitted to a rehabilitation unit suffered
from dysphagia and, in an earlier publication,
demonstrated that 39.5% (15/38) of brainstem patients
demonstrated
aspiration
on
videofluoroscopic modified barium-swallowing
(VMBS) (Table 3).4 Chua and Kong2 reported a
dysphagia incidence of 40% (21/53) in patients
with brainstem stroke, all of whom initially required tube feeding due to a high risk of aspiration. Similarly, Horner et al.7 found that 15 of the
23 brainstem patients included in their study
showed aspiration on VMBS. Current clinical
guidelines recommend all patients with high risk
for aspiration and/or dysphagia, including those
with brainstem stroke, be tested by VMBS.8
A brainstem stroke is believed to have a direct
effect on the swallowing centers and, hence, the
lower motor neurons.9 In addition, Miller et al.10
noted that the structure of the brainstem contains
dense packaging of cranial nuclei, sensory fibers,
neurons, and reticular interneurons that are vital
to swallowing. As a consequence, dysphagia following a brainstem stroke is often more severe and
the chances for spontaneous recovery are less
likely compared with dysphagia following a hemi-

spheric stroke.11 The higher incidence and greater
severity of dysphagia highlights the importance of
timely screening and appropriate management.
In a small sample (n = 6) of brainstem stroke
patients, Crary12 reported that a direct therapy
program, incorporating swallowing instruction
and biofeedback techniques over a period of at
least 3 weeks, proved beneficial and efficient for
brainstem stroke patients suffering from chronic
neurogenic dysphagia 5 months following stroke
onset. The program was designed to safely and
successfully institute oral feeding in high-risk patients. Following therapy, Crary12 reported patients established improved pharyngeal coordination and an increase in duration and effort (mean
and peak myoelectric motion) of swallowing musculature. Maintaining “oral and pharyngeal postures” during therapy helped to better swallowing
coordination posttreatment.
Patients with severe dysphagia may require enteral tube feeding. It is accepted that for patients in
whom it is anticipated that enteral feeds will be
required for less than a month, feeding can be
accomplished via nasogastric (NG) tube; whereas
gastrostomy and jejunostomy feeding tubes may
be utilized for patients who require enteral feeding
for a longer period.13 Teasell et al.13 reported
19.3% of patients with brainstem stroke admitted
to an inpatient rehabilitation unit required a percutaneous gastrojejunostomy (PGJ) feeding tube
before being discharged (Table 4) compared with
only 3.2% of patients with hemispheric stroke.
Enteral feeding tubes are frequently used in the
rehabilitation of dysphagia for brainstem stroke
Table 4. Use of PGJ tubes in patients with brainstem
stroke
Total pts
Pts with initial VMBS
Pts with aspiration on initial VMBS
% aspirators requiring PGJ tube
% pts requiring PGJ tube

88
33
29
51.7
19.3

Note: Pts = patients; VMBS = videofluoroscopic modified bariumswallowing; PGJ = percutaneous gastrojejunostomy.
Adapted from Teasell RW, Foley N, McRae M, Finestone H. Use of
percutaneous gastrojejunostomy feeding tubes in the rehabilitation of
stroke patients. Arch Phys Med Rehabil. 2001;82:1412–1415. Copyright © 2001 by Elsevier.

Rehabilitation of Brainstem Stroke Patients

patients, particularly in those patients who show
evidence of aspiration.
Although the occurrence of dysphagia appears
fairly high among patients with brainstem stroke,
the long-term result is favorable. Meng et al.14
found dysphagia present in 81% of patients with
brainstem stroke and, of these, 79% relied on tube
feeding at the time of initial evaluation. Four
months following stroke onset, 27 of the
brainstem stroke patients were contacted. Eightyeight percent of those contacted had resumed
complete oral intake.14 Similarly, Chua and Kong2
investigated 53 brainstem stroke patients admitted
to an inpatient rehabilitation institution, over the
course of 6 years. All patients relied on tube feeding on admission; however, after a very intense
rehabilitation program, only six patients required
tube feeding on discharge.
In general, treatment for dysphagia may include
compensatory strategies (including posture
change, swallowing manoeuvres, and heightened
sensory awareness), active exercise programs, or
diet modifications as well as nonoral feeding.8
Treatment recommendations provided in current
clinical guidelines include considering enteral
feeding for individuals unable to maintain adequate intake orally, possible use of a feeding tube,
and receipt of direct swallowing treatment and/or
management by a speech language pathologist
where available.8
Ataxia

Ataxia is defined as the loss or decreased ability
to coordinate muscle movement during voluntary
activity.1 Teasell et al.3 reported that 73/85 (86%)
of patients with brainstem stroke admitted to a
rehabilitation unit were ataxic upon admission,
while Chua and Kong2 reported a somewhat lower
incidence (68.9%) (Table 2). Patients with ataxia
suffer from movement inaccuracies including timing errors, irregular trajectories, delayed movements, imprecision during reaching activities, and
joint decomposition as a result of an inability to
produce muscle torques that predict and compensate for interaction torques generated during
multijointed movement.15
Studies examining treatment strategies for ataxia

61

are limited and diverse.1 Exercises specific for ataxic
patients include balance training, postural awareness training, motor learning, motor control, and
strengthening exercises.16 Postural control impacts
the function of upper extremity, which influences
the precision and rate of movement.1 Shifting
weight in any plane causes the trunk to compensate
for the alteration in the body’s center of gravity with
a compensatory movement.17 The Bobath treatment
approach (also known as neurodevelopmental
treatment [NDT]), currently popular among therapists, focuses on retraining a patient’s postural control and reactions,1,18 because posture is critical to
movement control. Postural training aims to stabilize movement for the upper limb and integrate
“postural control into activities of daily living.”1
Stoykov et al.1 reported improvements in movements of the upper extremity in an ataxic patient
following a brainstem stroke utilizing neuromuscular postural control exercises performed during
a 4-week course of rehabilitation. Exercises included maintaining sitting posture without support, strengthening truncal musculature via forward and backward rolling on the less affected
side, pelvis forward elevation and postural depression, trunk flexion, and reaching while weight
shifting. The patient demonstrated improved isolated control of distal and proximal movements in
the upper extremity along with quantifiable increases in function subsequent to the neuromuscular postural control intervention.1 However, few
studies have examined the treatment of apraxic
patients. Empirically, it has been shown that compensatory techniques (such as the use of external
support and distal weighting of limbs)1 improves
performance of ADLs. However, upper extremity
strengthening itself is reportedly not effective in
resolving coordination deficits.1
Dysarthria

Dysarthria has been defined as a “neurological
motor speech impairment that is characterized by
slow, weak, imprecise, and/or uncoordinated movements of the speech musculature and may involve
respiration, phonation, resonance, and/or oral articulations.”19 Dysarthria occurs when the areas of
the brainstem responsible for controlling speech are

62

TOPICS IN STROKE REHABILITATION/SEPT-OCT 2007

affected, thereby reducing coordination of respiratory and laryngeal muscles during speech. A common component of dysarthria is phonatory dysfunction.20 Robertson21 stated that poststroke
patients often experience a variety of “motor speech
parameters,” particularly intelligibility of speech
that results from inaccurate articulation caused by
poorly functional oro-facial muscle action. Dysarthria has been reported in 49% to 89% of patients
with brainstem stroke2,3 (Table 2), whereas studies
of all stroke types have reported lower frequencies
of only 20% to 30%.22–24
Treatment of dysarthria focuses on patients regaining normal muscle tone and increasing
strength in their facial and buccal muscles to improve movement accuracy and coordination.25
Treatment strategies generally involve reducing
ones’ rate of speech, pausing more frequently
throughout dialogue, taking deep breaths before
important words, and overarticulating certain syllables.26 In addition, specialized devices to improve intelligibility can be used. Sellars et al.27
found that devices vary from low-tech aids including alphabet boards to more advanced aids such as
computerized systems. Pacing boards assist patients in reducing their rate of speech,26,28 and sign
language can be used as an alternative if the
patient’s speech remains unintelligible.27 In addition, changing environments, training the listeners, or encouraging communicating more frequently with dysarthric patients can all decrease
the negative impact of dysarthria.29
The combination of a palatal lift and palatal
augmentation prosthesis can be effective when
used together with treatment by a speech language
pathologist. Palatal lifts help to improve
velopharyngeal closure and articulation and compensate for hypernasality during speech and articulation.30 Unfortunately, large-scale clinically
controlled trials examining the effectiveness of
dysarthria treatment are lacking.27
Paresis

Paresis is a result of damage at any point along
the corticospinal motor pathway31 and is common
in patients with brainstem stroke. Teasell et al.3
reported that 48% of patients recovering from
brainstem stroke suffered from some form of pare-

sis (Table 2). Chua and Kong2 found that paresis
was the most common neurological disorder, occurring in 94% of individuals with brainstem
stroke. Management of hemiparesis has been well
described in the stroke rehabilitation literature.
Dean and Shepherd32 demonstrated that taskrelated motor training was effective in improving
patients’ capability to maintain balance while sitting and performing reaching activities, as well as
using the lower extremity as support. This study
emphasized the importance of designing rehabilitation programs specific to the needs of patients
experiencing paralysis.
Alternatively, the restorative approach is used
more often for patients with mild-to-moderate
paresis and focuses on improvement of motor
function via strengthening, treadmill training with
partial body weight support, constraint-induced
movement therapy, and use of functional electrical
stimulation (FES).8 However, much of the literature derives from the study of hemispheric strokes
with cortical and subcortical involvement where
adjacent areas of cortex can take over lost function
and facilitate neurological recovery. Brainstem
stroke paresis does not involve the cerebral cortex
but rather the corticospinal tract and, theoretically,
reorganization within the cerebral cortex itself
plays a reduced role in recovery when hemiparesis
occurs in conjunction. Recovery is likely more
focused on reestablishing pathways from existing
cortical centers.
Diplopia

When the normal axis of vision is not aligned
because one eye has turned away due to cranial
nerve abnormality, diplopia is experienced. The incidence of diplopia following brainstem stroke has
not been frequently reported. Teasell et al.3 reported
that diplopia occurred in 38% of patients with
brainstem stroke (Table 2). The rehabilitation of
diplopia focuses on the realignment of the eyes.
Pambakian et al.33 described the rehabilitation strategies for patients with “homonymous visual field
defects” and noted that some of these strategies can
be used in the rehabilitation of patients suffering
from diplopia including optical aides such as “mirrors attached to spectacle frames, partially reflecting
mirrors (beam splitters) and diachronic mirrors

Rehabilitation of Brainstem Stroke Patients

(which reflect a red image and transmit a green
one), reversed telescopes, prisms, wide-angle
lenses, and closed circuit television monitors.”(p137)
These aids help relocate images to an area of the
vision field outside of the scotoma or increase the
visual field.33 Diplopia can also be improved
through simple techniques such as fogging, occlusion, suppressing vision in one eye, and pharmacologic measures, although these techniques do not
always provide the best result.34–37 Surgical procedures may be of benefit in the restoration of vision,
but they are only considered when rehabilitation
has failed, usually at least 6 months poststroke.36,38

63

Summary
Dysphagia/aspiration, ataxia, dysarthria, paresis,
and diplopia are all common impairments associated with patients with brainstem stroke. Rehabilitation of these patients often requires strategies
that are less commonly utilized in stroke rehabilitation. Further research is needed that focuses on
rehabilitation strategies specific to patients suffering from brainstem stroke, especially in the areas
of dysphagia and diplopia. In addition large-scale
clinically controlled trials examining the effectiveness of dysarthria treatment are lacking.

REFERENCES
1. Stoykov ME, Stojakovich M, Stevens JA. Beneficial
effects of postural intervention on prehensile action
for an individual with ataxia resulting from
brainstem stroke. NeuroRehabilitation. 2005;20(2):
85–89.
2. Chua KS, Kong KH. Functional outcome in brain
stem stroke patients after rehabilitation. Arch Phys
Med Rehabil. 1996;77(2):194–197.
3. Teasell R, Foley N, Doherty T, Finestone H. Clinical
characteristics of patients with brainstem strokes
admitted to a rehabilitation unit. Arch Phys Med
Rehabil. 2002;83(7):1013–1016.
4. Turney TM, Garraway WM, Whisnant JP. The natural
history of hemispheric and brainstem infarction in
Rochester, Minnesota. Stroke. 1984;15(5):790–794.
5. Garrison SJ, Rolak LA. Rehabilitation of the stroke
patient. In: De Lisa JA, Gans BM, eds. Rehabilitation
Medicine: Principles and Practice. Philadelphia, PA:
Lippincott; 1993:801–824.
6. Lorish TR, Sandin KJ, Roth EJ, Noll SF. Stroke rehabilitation. 3. Rehabilitation evaluation and management. Arch Phys Med Rehabil. 1994;75(5 Spec
No):S47–S51.
7. Horner J, Buoyer FG, Alberts MJ, Helms MJ. Dysphagia following brain-stem stroke. Clinical correlates
and outcome. Arch Neurol. 1991;48(11):1170–
1173.
8. Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg
JJ, Graham GD et al. Management of Adult Stroke
Rehabilitation Care: a clinical practice guideline.
Stroke. 2005;36(9):e100–e143.
9. Han DS, Chang YC, Lu CH, Wang TG. Comparison
of disordered swallowing patterns in patients with
recurrent cortical/subcortical stroke and first-time
brainstem stroke. J Rehabil Med. 2005;37(3):189–
191.
10. Miller AJ, Bieger D., Conklin JL. Functional controls
of deglutition. In: Perlman A, Schulze-Delrieu C, eds.
Deglutition and Its Disorders: Anatomy, Physiology,
Clinical Diagnosis and Management. San Diego:
Singlar Publishing Group; 1997:57–63.

11. Huckabee ML, Cannito MP. Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: a
retrospective evaluation. Dysphagia. 1999;14(2):
93–109.
12. Crary MA. A direct intervention program for chronic
neurogenic dysphagia secondary to brainstem
stroke. Dysphagia. 1995;10(1):6–18.
13. Teasell R, Foley N, McRae M, Finestone H. Use of
percutaneous gastrojejunostomy feeding tubes in
the rehabilitation of stroke patients. Arch Phys Med
Rehabil. 2001;82(10):1412–1415.
14. Meng NH, Wang TG, Lien IN. Dysphagia in patients
with brainstem stroke: incidence and outcome. Am J
Phys Med Rehabil. 2000;79(2):170–175.
15. Bastian AJ, Martin TA, Keating JG, Thach WT. Cerebellar ataxia: abnormal control of interaction
torques across multiple joints. J Neurophysiol.
1996;76(1):492–509.
16. Jette DU, Latham NK, Smout RJ, Gassaway J, Slavin
MD, Horn SD. Physical therapy interventions for
patients with stroke in inpatient rehabilitation facilities. Phys Ther. 2005;85(3):238–248.
17. Karatas M, Cetin N, Bayramoglu M, Dilek A. Trunk
muscle strength in relation to balance and functional disability in unihemispheric stroke patients.
Am J Phys Med Rehabil. 2004;83(2):81–87.
18. Mudie MH, Winzeler-Mercay U, Radwan S, Lee L.
Training symmetry of weight distribution after
stroke: a randomized controlled pilot study comparing task-related reach, Bobath and feedback training approaches. Clin Rehabil. 2002;16(6):582–592.
19. Yorkston KM. Treatment efficacy: dysarthria. J
Speech Hear Res. 1996;39(5):S46–S57.
20. Kent RD, Vorperian HK, Kent JF, Duffy JR. Voice
dysfunction in dysarthria: application of the MultiDimensional Voice Program. J Commun Disord.
2003;36(4):281–306.
21. Robertson S. The efficacy of oro-facial and articulation exercises in dysarthria following stroke. Int J
Lang Commun Disord. 2001;36 Suppl:292–297.
22. Arboix A, Marti-Vilalta JL, Garcia JH. Clinical study of

64

TOPICS IN STROKE REHABILITATION/SEPT-OCT 2007

227 patients with lacunar infarcts. Stroke.
1990;21(6):842–847.
23. Melo TP, Bogousslavsky J, van Melle G, Regli F. Pure
motor stroke: a reappraisal. Neurology. 1992;
42(4):789–795.
24. Warlow C, Dennis M, van Gijn J, Hankey GJ,
Sandercock P, Blamford J. Stroke: A Practical Guide to
Management. Oxford: Blackwell Scientific; 1996.
25. Netshell R. Physiological studies of dysarthria and
their relevance to treatment. In: Rosenbek J, ed.
Clinical Dysarthria. San Diego, CA: College-Hill Press;
1983:191–201.
26. Yorkston K, Beukelman D, Bell KR. Clinical Management of Dysarthric Speakers. London: Taylor &
Francis; 1987.
27. Sellars C, Hughes T, Langhorne P. Speech and language therapy for dysarthria due to nonprogressive
brain damage: a systematic Cochrane review. Clin
Rehabil. 2002;16(1):61–68.
28. Crow E, Enderby P. The effects of an alphabet chart
on the speaking rate and intelligibility of speakers
with dysarthria. In: Yorkston KM, Beukelman D, eds.
Recent Advances in Clinical Dysarthria. Boston, MA:
College-Hill Press; 1989:99–108.
29. Berry W, Sandars S. Environmental education: the
universal management for adults with dysarthria. In:
Berry W, ed. Clinical Dysarthria. Boston, MA: College-Hill Press; 1983:203–216.
30. Ono T, Hamamura M, Honda K, Nokubi T. Collaboration of a dentist and speech-language pathologist
in the rehabilitation of a stroke patient with dysarthria: a case study. Gerodontology. 2005;22(2):116–
119.
31. Cao Y, D’Olhaberriague L, Vikingstad EM, Levine SR,

Welch KM. Pilot study of functional MRI to assess
cerebral activation of motor function after
poststroke hemiparesis. Stroke. 1998;29(1):112–
122.
32. Dean CM, Shepherd RB. Task-related training improves performance of seated reaching tasks after
stroke. A randomized controlled trial. Stroke.
1997;28(4):722–728.
33. Pambakian A, Currie J, Kennard C. Rehabilitation
strategies for patients with homonymous visual field
defects. J Neuroophthalmol. 2005;25(2):136–142.
34. Rozenblium I, Chernysheva SG, Kapranova AS,
Belozerov AE, Petrenko AE. [Clinical picture and
treatment of diplopia]. Vestn Oftalmol. 2000;
116(5):18–21.
35. Silverberg M, Schuler E, Veronneau-Troutman S,
Wald K, Schlossman A, Medow N. Nonsurgical
management of binocular diplopia induced by
macular
pathology.
Arch
Ophthalmol.
1999;117(7):900–903.
36. Kushner BJ. Recently acquired diplopia in adults
with long-standing strabismus. Arch Ophthalmol.
2001;119(12):1795–1801.
37. Rutstein RP, Cogen MS. Elimination of paradoxical
diplopia following treatment with botulinum toxin
and prism. Binocul Vis Strabismus Q. 2004;19(1):35–
38.
38. Iseli HP, Hafezi F, Mojon DS. Conservative treatment
of vertical diplopia in a patient with silent sinus syndrome. Ophthalmologica. 2003;217(4):308–309.
39. Gowland C, Stratford P, Ward M, et al. Measuring
physical impairment and disability with the
Chedoke-McMaster Stroke Assessment. Stroke.
1993;24(1):58–63.