Review Article

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Address correspondence to
Dr Samir R. Belagaje, Emory
University, 80 Jesse Hill Jr Dr
SE, Faculty Office Bldg, Room
375, Atlanta, GA 30303,
sbelaga@emory.edu.
Relationship Disclosure:
Dr Belagaje reports
no disclosure.
Unlabeled Use of
Products/Investigational
Use Disclosure:
Dr Belagaje discusses the
unlabeled/investigational use
of fluoxetine for poststroke
motor recovery treatment,
cholinesterase inhibitors and
memantine for the treatment
of aphasia, and dopaminergic
agents to aid in the treatment
of poststroke depression.
* 2017 American Academy
of Neurology.

Stroke Rehabilitation
Samir R. Belagaje, MD
ABSTRACT
Purpose of Review: Rehabilitation is an important aspect of the continuum of care
in stroke. With advances in the acute treatment of stroke, more patients will survive
stroke with varying degrees of disability. Research in the past decade has expanded
our understanding of the mechanisms underlying stroke recovery and has led to the
development of new treatment modalities. This article reviews and summarizes the
key concepts related to poststroke recovery.
Recent Findings: Good data now exist by which one can predict recovery, especially
motor recovery, very soon after stroke onset. Recent trials have not demonstrated a
clear benefit associated with very early initiation of rehabilitative therapy after stroke in
terms of improvement in poststroke outcomes. However, growing evidence suggests
that shorter and more frequent sessions of therapy can be safely started in the first
24 to 48 hours after a stroke. The optimal amount or dose of therapy for stroke
remains undetermined, as more intensive treatments have not been associated with
better outcomes compared to standard intensities of therapy. Poststroke depression
adversely affects recovery across a variety of measures and is an important target for
therapy. Additionally, the use of selective serotonin reuptake inhibitors (SSRIs)
appears to benefit motor recovery through pleiotropic mechanisms beyond their
antidepressant effect. Other pharmacologic approaches also appear to have a benefit
in stroke rehabilitation.
Summary: A comprehensive rehabilitation program is essential to optimize poststroke
outcomes. Rehabilitation is a process that uses three major principles of recovery:
adaptation, restitution, and neuroplasticity. Based on these principles, multiple
different approaches, both pharmacologic and nonpharmacologic, exist to enhance
rehabilitation. In addition to neurologists, a variety of health care professionals are
involved in stroke rehabilitation. Successful rehabilitation involves understanding the
natural history of stroke recovery and a multidisciplinary approach with judicious use of
resources to identify and treat common poststroke sequelae.
Continuum (Minneap Minn) 2017;23(1):238–253.

INTRODUCTION
Stroke is the fifth leading cause of
death and a leading cause of longterm disability in the United States.
The economic impact of a stroke is tremendous. By 2030, total direct annual
stroke-related medical costs are expected to increase from $71.55 billion
in 2012 to $184.13 billion, and indirect annual costs are expected to
rise from $33.65 billion in 2012 to
$56.54 billion.1 Because of the recent
advances in acute stroke treatment

238

and neurocritical care, more patients
now survive stroke, with varying degrees of disability.
In general, neurologists are familiar
with acute stroke treatments and
prevention strategies but tend to be
less familiar with aspects of stroke
rehabilitation. Because neurologists
are involved in the continuum of
stroke care in both inpatient and
outpatient settings, it is important to
be knowledgeable in this important
aspect of stroke. At the very least, this

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February 2017

knowledge will help neurologists to
educate stroke survivors and their
families on the prognosis and secondary complications of stroke,
identify barriers to recovery, and
develop individualized plans to help
patients improve.
STROKE REHABILITATION VERSUS
STROKE RECOVERY
It is important to differentiate between stroke recovery and stroke
rehabilitation. These two terms are
often used interchangeably in the
clinical setting and literature but important differences exist. Stroke rehabilitation has been broadly defined as
any aspect of stroke care that aims to
reduce disability and promote participation in activities of daily living.
Stroke rehabilitation is a process; its
objectives are to prevent deterioration
of function, improve function, and
achieve the highest possible level of
independence (physically, psychologically, socially, and financially) within
the limits of the persistent stroke
impairments. During this process,
treatment and training are provided
to stroke survivors to help them
return to normal life. By regaining
and relearning skills of everyday liv-

ing through rehabilitation, many stroke
survivors obtain greater independence
in activities of daily living and improved functional capacity.2 Table 11-1
lists the major rehabilitation approaches, the goals of each approach,
and an example.3
On the other hand, stroke recovery
may be best defined as improvement
across a variety of outcomes, beginning with biological and neurologic
changes that manifest as improvement on performance and activitybased behavioral measures. A variety
of measures exist, and, depending
on the definition of successful recovery, the proportion of patients classified as recovered in stroke outcome
studies can vary markedly. For example, Duncan and colleagues4 compared patterns of recovery using
different outcome measures and varying thresholds for defining successful recovery. The percentage of
patients who achieved full recovery
at 6 months differed based on the
scale and how recovery was defined.
Therefore, recovery may not necessarily reflect functional improvement
either behaviorally or biologically. It is
important to tailor the definition of
recovery to the individual patient and

KEY POINT

h Rehabilitation is a process
of stroke care that
reduces disability and
improves participation in
therapy. Recovery is
defined as improvements
across a variety
of outcomes.

TABLE 11-1 Rehabilitation Approaches and Goals
Approach

Goals

Example

Restoration

Retrain parts of the central nervous
system to engage lost functions;
restore the function of damaged
brain tissue

Home exercise program
to improve hemiparesis

Compensation

Adapt behavior to the loss of
function without changing the
impairments, or reorganization
of partially spared brain pathways
to relearn lost functions

Use of prisms in glasses
to address poststroke
diplopia

Modification

Altering environmental setting to
promote function and activities
of daily living

Adding rails in shower to
assist with transfers and
prevent falls

Continuum (Minneap Minn) 2017;23(1):238–253

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239

Stroke Rehabilitation
KEY POINTS

h The human brain
recovers from a stroke
through adaptation,
regeneration, and
neuroplasticity.

h Neuroplasticity is driven
by principles of task
specificity, repetition,
and challenge.

240

develop a rehabilitation plan to reach
the defined recovery goals.
A human brain recovers from stroke
in three main ways: adaptation, regeneration, and neuroplasticity. Most
successful rehabilitation techniques
incorporate at least one of these
processes. Adaptation is the reliance
on alternative physical movements or
devices to compensate for poststroke
deficits. An example would be the use
of the nondominant hand to feed
oneself after hemiplegia affecting
dominant hand function. Assistive devices include a walker for poststroke
gait and balance dysfunction and
prisms in glasses to compensate for
visual field deficits. While adaptation
is helpful, it may also be harmful to the
recovery process because of learned
disuse. This phenomenon occurs
when individuals do not use their
affected limb because they have developed habits to complete actions
and tasks bypassing use of the limb,
even though they have the capacity to
use it. Limiting use of the limb can also
limit its recovery.
Regeneration is the growth of neurons and associated cells and circuity
to replace those damaged from a
stroke. This approach has historically
been considered least useful in stroke
rehabilitation as it was believed that
central nervous system tissue did not
have the capacity for regrowth after
injury. However, regeneration has
been the focus of attention in recent
years because of research advances in
stem cell and growth factor interventions. At this time, it is not considered a standard clinical aspect of
stroke recovery. Questions still exist
regarding the type of stem cell to
use, how to deliver it (intravenously,
via surgical resection, or endovascularly), dosing, and long-term safety
effects. Nevertheless, ongoing clinical
trials are attempting to answer these

questions, and regeneration holds
hope for the future.
Neuroplasticity, generally defined
as changes or a rewiring in the neural
network, is considered to be the main
recovery process. Soon after a stroke,
activation is decreased in cortical areas
directly affected by the stroke. This
reduced activity is associated with a
change in the localization of certain
tasks such as movement. As time
progresses through the acute and
subacute period, the neural networks
that had been disrupted by the
stroke reconnect in areas adjacent to
the area of stroke and coincide with
clinical recovery. For example, functional neuroimaging techniques show
that as hand function improves, cortical representation that once subserved the hand moves toward the
cortical face area (Figure 11-15).6 This,
in turn, causes an activation in the periischemic area/ischemic area with return
of laterality to functions and alteration
of representative cortical maps. Furthermore, the amount of recovery
correlates with the degree of activation
in the peri-infarct areas. In general, less
functional poststroke recovery is seen
in neural networks that have activation
in areas more widely distributed beyond the peri-infarct territory.
Research studies have demonstrated
that neuroplasticity is driven by several key principles. For plasticity to
fully occur, rehabilitation interventions must be task specific and goal
directed rather than general and
nonspecific movements. Furthermore,
the goal-directed tasks must be challenging and interesting enough to
maintain an individual’s attention,
and the task should allow for repetition through multiple attempts.7Y9
NATURAL HISTORY OF STROKE
Most stroke deficits will see the
highest rate of recovery during the

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February 2017

FIGURE 11-1

Three patterns of evolution of functional MRI (fMRI) activation after middle
cerebral artery stroke and use of the affected hand for three different patients.
As time progresses, the activated sites become more consolidated, lateralized,
and smaller.

Modified with permission from Feydy A, et al, Stroke.5 B 2002 American Heart Association, Inc. stroke.ahajournals.org/
content/33/6/1610.long.

first 3 to 6 months after stroke. After
6 months, recovery then reaches a
plateau phase without additional significant improvement. However, exceptions exist, and improvement can
continue for several years after stroke.
Models to predict potential for recovery beyond 6 months and interventions
Continuum (Minneap Minn) 2017;23(1):238–253

to facilitate continued recovery in the
plateau phase remain an active area of
clinical research.
Swallowing, facial movement, and
gait tend to demonstrate better recovery than other deficits. One hypothesis
to explain this observation is that these
deficits have bihemispheric representation
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241

Stroke Rehabilitation
KEY POINTS

h Different functions
recover differently.
Swallowing, facial
movement, and gait
tend to have better
recovery than language
and dominant hand
function.

h Upper extremity motor
recovery can be predicted
very early at the bedside
through the presence/
absence of voluntary
finger extension and
shoulder abduction.

242

in the cortex as part of their normal
functional anatomy.10,11 On the other
hand, cortical functions, such as language and spatial attention as well as
dominant hand movement, are more
lateralized in functional anatomy and
consequently recover more slowly.10
In addition to the limitations of spontaneous recovery, multiple factors play
a role in the plateau of recovery. Limited
therapy or absence of therapy often
leads to learned disuse and hinders
improvement.12 Poststroke depression
has been shown to impede recovery
across a variety of measures such as
cognitive deficits and mortality. Other
factors that can hinder recovery include
side effects of medications, such as
excessive benzodiazepine use, and physical comorbidities, such as cervical
spine disorders. Neurologists managing the patient with stroke in the acute,
subacute, and chronic settings should
attempt to ensure that patients are receiving appropriate therapy and are
periodically screened for depression.
Good data exist to predict recovery
very soon after stroke onset. Motor
recovery tends to begin in the proximal musculature of the upper and
lower extremities and progresses.
The Early Prediction of Functional
Outcome After Stroke (EPOS) study
found that recovery of upper extremity function at 6 months could be
accurately predicted if voluntary finger
extension and shoulder abduction
were present at 48 hours poststroke.13
In fact, if these movements were
present, the probability of a good
outcome was 98%; if finger extension
was not present within 48 hours, the
probability of a good outcome was 25%.
If the movements did not improve
by day 9 poststroke, the likelihood of
complete upper extremity recovery
decreased to 14%.13 Similar predictive
models are being developed for recovery of lower extremity deficits.14

TIMING AND INTENSITY OF
REHABILITATION
Uncertainty remains as to the optimal
timing and intensity of rehabilitation.
In a study examining differences in
outcomes for patients for whom therapy was initiated 20 days apart, a
strong inverse relationship between
the start date and functional outcome
was observed, albeit with wide confidence intervals.15 In other words,
those who initiated therapy soon after
stroke onset exhibited significantly
higher effectiveness of treatment than
did the medium- or late-initiating groups.
Treatment initiated within the first
20 days was associated with a significantly higher probability of excellent
therapeutic response compared to treatment beginning at 20 or 40 days. These
findings should not be surprising given
the natural history of stroke recovery
as previously discussed.
Consensus is lacking as to when to
start rehabilitation after stroke as
specific guidelines for early mobilization do not exist. Patients with stroke
who receive thrombolytic therapy are
often immobilized for at least 24 hours
to minimize complications from recombinant tissue plasminogen activator. One reason is that strict blood
pressure guidelines are placed on
patients after thrombolysis to reduce
the risk of hemorrhage. Therefore,
clinicians may be hesitant to increase
physical activity in these patients for
fear that an elevation in blood pressure may result. In addition, patients
treated with endovascular arterial reperfusion are often confined to bedrest
to minimize the risk of complications
related to femoral access. However,
prolonged bedrest increases the risk
of complications related to immobility,
including pressure sores, aspiration
pneumonia, and deep vein thrombosis.
In the A Very Early Rehabilitation
Trial (AVERT), 2104 patients who were

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February 2017

hospitalized with either ischemic or
hemorrhagic strokes were randomly
assigned to receive customary therapy
or a very early intervention. In the
intervention arm, the first mobilization
was aimed to begin within 24 hours
following stroke onset, with the additional goals of the patient being
upright and out of bed at least twice
daily. This intervention continued for
the first 14 days poststroke or until
discharge from the acute stroke unit
and was delivered by a physical therapy team, including a trained nurse.
Those who were mobilized had a
worse outcome, defined as a modified
Rankin Score of less than 3, compared
to standard care (46% versus 50%;
adjusted odds ratio = 0.73, P = .004).16
However, in a prespecified doseresponse analysis of the trial, it appears
that shorter but more frequent sessions
of early mobilization improved patients’
chances of regaining independence.17
Similarly, early rehabilitation starting
within 48 hours demonstrated benefit
in 6-month survival and functional outcomes in patients with intracerebral
hemorrhage.18
Once therapy is initiated, unanswered questions exist regarding the
‘‘dose’’ of rehabilitation. Analogous to
medications prescribed for stroke,
variations in the duration and intensity
of rehabilitation therapy affect recovery outcomes. However, the exact
nature of this relationship in unclear.
Data from the Very Early ConstraintInduced Movement During Stroke
Rehabilitation (VECTORS) trial, a study
of the amount of therapy and motor
improvement after stroke, suggest that
more therapy does not always result in
significantly better outcomes. This
single-blind phase 2 randomized trial
compared traditional upper extremity
therapy with dose-matched and highintensity constraint-induced movement
therapy protocols administered over
Continuum (Minneap Minn) 2017;23(1):238–253

the course of 2 weeks in 52 patients
with upper extremity weakness from
either ischemic or hemorrhagic strokes.
The therapy was started in the first
28 days after a stroke. Improvement,
as measured by the Action Research
Arm Test (ARAT) score, was demonstrated in all groups; the high-intensity
constraint-induced movement therapy group had significantly less improvement at day 90 compared to
the dose-matched constraint-induced
movement therapy and control groups
at day 90.19 Similarly, animal models
have demonstrated enlargement in
areas of ischemia correlating with
poor function when constraint therapy is applied early after a stroke.20 It
is not clear why early use of constraint
therapy impairs early recovery; however, as this therapy is more intense
than conventional therapies, greater
ischemic demand exists, which can
cause neurologic injury. Based on these
results, it appears that more data are
needed before any definite conclusions
can be made about the early application
of intense therapy such as constraintinduced movement therapy.
In the 2016 Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) trial, 361 subjects were
given rehabilitation in one of three
arms: an Accelerated Skill Acquisition
Program, dose-equivalent usual and
customary occupational therapy, or
usual and customary occupational
therapy. Motor outcomes were not
significantly different between the
three groups.21
Based on the results of these
studies, answers to the dosing question remain elusive. Generally accepted practice at this time includes
consulting therapists to first evaluate
patients within the first 48 hours,
using less intense therapy practices
as determined by the rehabilitation
teams and tolerated by patient, and,

KEY POINT

h The generally accepted
practice for stroke
rehabilitation at this
time involves using less
intense therapy in the
acute/hyperacute
setting and increasing
the intensity for those
who can tolerate it in
the rehabilitation/
outpatient setting.

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243

Stroke Rehabilitation
KEY POINT

h Based on current
guidelines, inpatient
rehabilitation facilities
are appropriate
posthospital discharge
locations for patients
who are able to actively
participate in two
disciplines of therapy for
3 hours per day, have
medical issues requiring
physician supervision,
and have a reasonable
expectation of resuming
community living.

244

for those who can tolerate it, increasing the intensity of rehabilitation in
the rehabilitation/outpatient setting.
THERAPY APPROACHES TO
REHABILITATION
A goal of stroke rehabilitation should
be to facilitate relearning of skills that
were possible before the stroke, but in
some cases the focus of rehabilitation
must be adaptation and compensation
for deficits. This process begins while
the patient is hospitalized for stroke
and involves motor skill retraining,
preventing complications, and teaching adaptive techniques using a comprehensive approach. In the US health
care system, stroke survivors in need
of further rehabilitation following the
acute hospitalization have three possible posthospital dispositions: (1)
home with outpatient therapy, (2)
home with home health therapy, or
(3) inpatient rehabilitation facility or
skilled nursing facility placement. The
disposition is based on the nature and
severity of deficits, comorbidities, and
insurance/reimbursement. For example, inpatient rehabilitation facilities
are available to patients who are able
to actively participate in at least two
disciplines of therapy (physical therapy, occupational therapy, or speech
and language therapy) for 3 hours
per day, have medical issues requiring physician supervision, and have a
reasonable expectation of resuming
community living. The length of stay
in these settings is dependent on a
variety of factors, including the severity of neurologic deficits, medical
comorbidities, and rehabilitation progress; on average, the length of stay is
about 2 weeks. It is important to note
that in many areas of the United States,
the presence and type of third-party
insurance will determine where patients continue rehabilitation following
acute hospital discharge. Consequently,

unfortunately, many stroke survivors
who are uninsured or underinsured,
despite being good candidates for inpatient rehabilitation facilities, are discharged to a skilled nursing facility.
The importance of posthospital discharge disposition on outcomes is
discussed later in this article.
Rehabilitation is often provided in a
team-based approach and involves
various disciplines, such as physical
therapy, occupational therapy, and
speech and language therapy. The
role of the team involves setting goals,
reevaluating these goals on a regular
basis, and making adjustments to the
rehabilitation plan as needed. In addition to improving the function of the
patient, caregiver training is an important aspect of rehabilitation.
Physical therapists perform evaluations to detect problems with movement and balance. They work with the
patient and the rehabilitation team to
perform exercises to strengthen muscles for walking, standing, and other
activities. Occupational therapists help
stroke survivors learn strategies to
manage daily activities such as eating,
bathing, dressing, writing, and cooking. One simple way to differentiate
between physical and occupational
therapy is that the focus of physical
therapy is on the lower extremities,
while occupational therapy focuses on
upper extremity impairments, but it is
important to note that this is a generalization and there are exceptions and
nuances in this difference.
Speech and language pathologists
(ie, speech therapists) help stroke
survivors learn strategies to overcome
swallowing and language deficits. In
the acute setting, they are involved
with dysphagia and swallowing evaluations and may make recommendations for alternative methods of oral
intake, such as nasogastric tubes or
percutaneous endoscopic gastrostomy

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February 2017

tubes. In the subacute and outpatient
settings, aphasia tends to be the focus
of speech and language therapy.
Following the initial evaluation,
therapists develop a program and
provide exercises that use the principles of neuroplasticity mentioned previously (task specificity, repetition,
challenging). Teaching of compensatory and adaptive techniques is another important goal. Therapists train
the patient and family in activities
such as safe transfers, assisted ambulation, proper feeding, and provision
of appropriate adaptive techniques.
Device-based and adjunctive therapies, such as robotic arms and bodyweight support treadmills, have been
proposed; however, studies have
failed to demonstrate their superiority over currently used therapies and
evidence to support regular clinical
use is lacking.22,23
Several nontraditional strategies
have demonstrated improved efficacy
compared to traditional therapy.
Constraint-induced movement therapy is a motor rehabilitation therapy
technique in which the unaffected
extremity is constrained with a mitt,
thereby forcing use of the affected
hand. This approach, even in a modified dose using a decreased frequency
of constraint-induced movement therapy, has been shown to be more effective than standard therapy in the
3- to 9-month poststroke window.24,25
Melodic intonation therapy has
been shown to enhance recovery of
poststroke aphasia.26 Melodic intonation therapy uses musical elements,
including melody and rhythm, to
improve language production. The
theoretical basis of this approach is
that language is localized in the dominant hemisphere, but singing and
melody localize to the nondominant
hemisphere. Consequently, advocates
of this therapy take advantage of
Continuum (Minneap Minn) 2017;23(1):238–253

preserved singing abilities in the
unaffected hemisphere and engage
language-capable regions in the nondominant (usually right) hemisphere.
While robust evidence for this approach is lacking, it appears that this
therapy is most beneficial in stroke
survivors with expressive (Broca)
aphasia but with some retained expressive abilities as well as absent bihemispheric damage.
Functional electrostimulation is another technique than can be used to
enhance motor recovery in patients
with stroke.27,28 This technique involves applying electrical stimulation
to muscles of interest. Functional
electrostimulation devices are commercially available, and improving these
types of devices is an area of active
research interest. An example of a
functional electrostimulation device is
shown in Figure 11-2.
Following a stroke, it is important
that the rehabilitation setting is appropriate and optimized for the individual patient. Patients who receive
their posthospital rehabilitation in an

KEY POINTS

h Constraint-induced
movement therapy is an
alternative motor
rehabilitation therapy
technique for the upper
extremity in which the
unaffected extremity is
constrained with a mitt,
thereby forcing use of
the affected hand.

h Melodic intonation
therapy is an alternative
therapy technique that
has been shown to
enhance recovery of
poststroke aphasia. It
involves the use of
musical elements,
including melody and
rhythm, to improve
language production.

An example of a functional electrostimulation
device that provides electrical stimulation to
muscles of the forearm and hand to enable a
stroke survivor to extend the wrist and flex fingers. The
stimulation intensity can be adjusted depending on the level
of the patient’s weakness and progress with therapy. It is
portable and can be used at home.

FIGURE 11-2

Courtesy of Bioness Inc.

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245

Stroke Rehabilitation
KEY POINT

h When patients with
stroke are unable to
return home following
their acute hospitalization,
discharge to an inpatient
rehabilitation facility
will likely result in
a better outcome.

inpatient rehabilitation facility have
improved outcomes following endovascular therapy compared to those in
a subacute or skilled nursing facility.29
In a cohort with no significant differences in age, comorbidities, infarct
volume, or recanalization rates, patients who went to a skilled nursing
facility had significantly worse outcomes than those patients who went
to an inpatient rehabilitation facility.30
These points are important for clinicians to remember when deciding on
appropriate postacute care and discharge disposition for patients with
stroke as there may be confounders
and the appropriate destination may
not be immediately clear. These
points are illustrated in Case 11-1.
PHARMACOLOGIC APPROACHES
TO STROKE REHABILITATION
Medications can also play a role in
promoting stroke recovery. The Flu-

oxetine for Motor Recovery After
Acute Ischaemic Stroke (FLAME) trial
was a randomized double-blind
placebo-controlled trial comparing
fluoxetine 20 mg/d and placebo beginning 5 to 10 days after stroke onset in patients with hemiplegia or
hemiparesis.31 In the intervention
group, the change in motor function, as measured by the Fugl-Meyer
Assessment of Sensorimotor Recovery After Stroke score, was significantly higher than in the placebo group.31
The study results suggest that, rather
than just treating poststroke depression (which was addressed in the
trial), selective serotonin reuptake
inhibitors (SSRIs) may also impact
motor recovery, likely through neuroplastic mechanisms. Other antidepressant or neuro-modulating agents
have also been examined with positive benefits. For example, clinical trials
using cholinesterase inhibitors and

Case 11-1
An 80-year-old woman presented with a right middle cerebral artery
distribution acute ischemic stroke. She received both IV recombinant tissue
plasminogen activator and mechanical thrombectomy. She was admitted
to the hospital for further testing and close monitoring. Despite the acute
therapy she still had deficits from her stroke. On hospital day 3, she was
evaluated by the therapy team and found to be lethargic and participating
poorly in therapy. Because of her lethargy, the therapy team determined
that she was unable to participate in her 3 hours of therapy per day and
recommended skilled nursing facility placement. Evaluation by the primary
team revealed that she had a low-grade fever and leukocytosis and a
urinalysis suggestive of a urinary tract infection. Antibiotics were started,
and she improved over the next 2 days. Her ability to participate in therapy
sessions improved, and the discharge recommendation was upgraded to
an inpatient rehabilitation facility.
Comment. This case is an example of how neurologic status can be
confounded by infection-induced encephalopathy, a condition that is
reversible with appropriate treatment, and illustrates the potential
mutability of posthospital discharge recommendations in a short period
of time. Had the primary team just proceeded with the initial discharge
recommendations and not addressed and treated her confounders to
participation in therapy, and had not pursued a repeat evaluation by
the therapy team, it is likely that her poststroke recovery would have
been compromised.

246

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February 2017

glutamatergic agents suggest improvements in aphasia rehabilitation.32Y34
Similarly, it appears that dopaminergic
medications may help address poststroke depression and attention.35,36
The trials are limited by their small
numbers, heterogeneity of stroke size,
and locations. Given these limitations,
insufficient evidence exists to implement the medications in routine clinical practice. However, as the safety
profile of these interventions is reasonably demonstrated, in certain situations
it would be reasonable to consider
these pharmacologic agents as part
of the rehabilitation plan of patients
after discussion with patients and
care teams.
Certain medications can impair
poststroke recovery, in particular when
used in the acute period. Based on
their mechanistic effect on neurotransmitters, older antiepileptic agents,
such as phenobarbital, diazepam, and
phenytoin, can impede synaptic formation in animal models.37 To avoid
such detrimental effects on poststroke
recovery, newer-generation antiepileptic drugs should be considered
as the first-line treatment for poststroke seizures.
H2 blockers (such as famotidine or
ranitidine) are a type of antihistamine
used during hospitalizations to reduce
the risk of gastric reflux and counter
the potential gastrointestinal side effects of antithrombotic medications
such as aspirin. Since antithrombotics
are an evidence-based intervention for
secondary stroke prevention, the use
of H2 blockers is widespread. However,
antihistamines can cause sedation in
patients who are elderly and compromise attention vital for effective performance of motor and cognitive tasks.
Evidence suggests that these medications can impede plasticity through
inhibition of long-term potentiation.38
Given this potential risk of treatment,
Continuum (Minneap Minn) 2017;23(1):238–253

proton pump inhibitors are preferable
to H2 blockers in this setting.
SPECIFIC ISSUES IN STROKE
REHABILITATION
While each stroke presents its own
individual issues in rehabilitation due
to factors such as stroke size, stroke
location, and patient comorbid factors,
several common themes or issues
often present. This section reviews the
most common sequelae and issues
impeding overall recovery and quality of life.

KEY POINTS

h Caution and careful
consideration must be
used when prescribing
antiepileptic medications
and antihistaminergic
medications as they
may adversely affect
stroke recovery.

h Shoulder pain is a
common sequela after a
stroke and may be
caused by a variety
of conditions.

Shoulder Syndrome
Loss of arm function is a common
poststroke outcome and results in
shoulder pain in up to 70% of patients
with upper extremity dysfunction.39
Shoulder pain delays recovery as the
painful joint limits participation in
rehabilitation and may mask improvements in motor function. Shoulder
pain can result from multiple causes,
including subluxation, impingement,
complex regional pain syndrome, thalamic pain syndrome, spasticity, or
other conditions such as radiculopathies. To discern between the various
causes of shoulder pain, careful assessments of both normal and affected
shoulders and ranges of motion (passive and active) are required. A palpable fingerbreadth gap between the
acromion and humeral head suggests
joint subluxation. A restricted range of
movement without pain at rest but
present on limited movement suggests adhesive capsulitis as the primary pathology.
Treatment for shoulder pain should
begin early by recognizing patients at
risk for shoulder syndromes. Patients
with flaccid upper extremity paresis
are prone to shoulder subluxation and
traction in the glenohumeral capsule,
which lead to damage of surrounding
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247

Stroke Rehabilitation
KEY POINT

h Depression is a common
sequela after a stroke
and adversely affects
outcomes. Medications
such as selective serotonin
reuptake inhibitors can
be effectively used in
the treatment of
poststroke depression.

soft tissues. Proper positioning that
includes supporting the distal forearm
from the elbow down to reduce strain
at the shoulder reduces the tension
on the shoulder; slings can be used to
provide additional support. Strapping
or taping of the upper arm to the
shoulder and clavicle has been used
routinely in the management of subluxation. An intraarticular cortisone
injection (1 mg to 5 mg) into the glenohumeral joint can be used to treat
pain in patients with adhesive capsulitis.
Functional electrostimulation can be
used for muscle contraction and pain
relief. The management of spasticity is
discussed later in this article.
Depression
Poststroke depression is increasingly
recognized as a common sequela
of stroke. The prevalence of clinically diagnosed poststroke depression
ranges from 20% to 40%, and it is
likely underdiagnosed.40Y42 The interaction between depression and stroke
recovery is complex, but when depression is untreated or undertreated
in patients, poststroke recovery is not
optimized. Depression symptoms (eg,
fatigue, reduced motivation, loss of
confidence, and attention and concentration difficulties) limit the benefits of rehabilitation and can even

counteract them. Studies show that
higher rates of mortality and morbidity are seen in stroke patients diagnosed with poststroke depression,43,44
while treatment of depression leads to
improved functional recovery after
stroke. Moreover, by restoring the
balance of central neurotransmitters,
improving motivation to work with rehabilitation therapists, and increasing
compliance with medications, treatment of depression leads to improved
functional recovery after stroke.
SSRIs are the most studied agents
for the treatment of poststroke depression. Evidence exists for the use
of citalopram (20 mg/d), sertraline
(50 mg/d to 100 mg/d), and fluoxetine
(20 mg/d), which are superior to
placebo in treating poststroke depression and producing improvement in
quality-of-life measures.45Y47 Evidence
also supports the efficacy of tricyclic
antidepressants for the treatment of
poststroke depression.48 Case 11-2
is a clinical example of how poststroke depression affects recovery and
its treatment.
Spasticity
Spasticity is a motor disorder generally
defined as a velocity-dependent increase in tonic stretch reflexes leading
to increased tone. It is often identified

Case 11-2
A 45-year-old man was admitted to the hospital with a basal ganglia lacunar
stroke. Despite having a small stroke with minimal comorbidities and mild
to moderate deficits, the patient was not improving. His therapists reported
decreased participation and minimal functional gains in therapy sessions.
The patient reported increased fatigue and somnolence, and his family noted
poor engagement and a change in personality. Poststroke depression was
diagnosed. He was started on citalopram 20 mg/d, with gradual improvement
in his mood and other symptoms.
Comment. This case illustrates the importance of screening for poststroke
depression and having a low threshold to treat it. It is important to note
that the effect of selective serotonin reuptake inhibitors (SSRIs) may not be
seen for 1 to 2 weeks.

248

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February 2017

during the chronic phase of poststroke recovery. At 12 months, patients
without spasticity have shown significantly better motor and activity scores,
have lower Barthel Index scores, and
are less likely to receive institutional
care (PG.0001) compared to those with
spasticity.49 Likewise, another study
demonstrated that modified Rankin
Scale and Barthel Index scores were
greater for patients with spasticity than
for patients without spasticity.50 These
studies show that spasticity adversely
affects functional outcomes in the
chronic phase of stroke; therefore,
management of spasticity is an essential part of stroke rehabilitation.
Historically, treatment of spasticity
has involved oral medications such as
baclofen, nerve blocks, and serial
casting, but these interventions are
limited because of side effects. Alternatively, botulinum toxin and intrathecal baclofen are now widely accepted
in the management of spasticity in patients with chronic stroke. Compared
to the oral route, intrathecal baclofen
achieves muscle-relaxing properties at
significantly lower doses, thus limiting
systemic side effects. In studies of
intrathecal baclofen in patients who
were poststroke with spasticity, improvement was seen in mobility, activities of daily living, and quality of life.51
Botulinum toxin is beneficial for
poststroke spasticity, demonstrating
improvement in upper limb musculature tone. In studies supporting its use,
botulinum toxin was administered into
muscles of interest in the hand, wrist,
and upper arm at least 6 weeks poststroke. Study participants had a Modified Ashworth Scale score of 2 to 3 in
upper extremity muscles of interest and
were followed for at least 10 weeks.52
Return to Work
A common concern of stroke survivors regards return to employment. In
Continuum (Minneap Minn) 2017;23(1):238–253

addition to financial independence
and full integration into society, patients enjoy subtle benefits from employment, such as improvement in
self-esteem and confidence. Clinicians
often concentrate on the severity of
physical and cognitive impairments
when considering a patient’s ability
to return to work; however, studies
have demonstrated that other factors,
such as younger age, educational
level, level of skill, and prestroke professional status, appear to be strong
influencers of a patient’s ability to
return to work.53,54 Vocational rehabilitation programs are available for
patients, and often neuropsychological testing can help assess a patient’s
cognitive ability to return to work. For
patients who are deemed unable to
return to work, health care teams
should assist patients with completing
temporary disability forms or longterm disability forms, if needed.

KEY POINTS

h Spasticity adversely affects
poststroke outcomes.

h Botulinum toxin
and intrathecal baclofen
are the preferred
treatments of spasticity
in patients with
chronic stroke.

h Studies show that the
severity of physical and
cognitive impairments is
not associated with a
stroke survivor’s ability
to return to work. More
important factors
include age, educational
level, and prestroke
professional status.

Return to Driving
The ability to drive plays an important
role in routine activities and frequently
serves as the key to independence.
Stroke survivors are often restricted
in their driving ability because of
hemiparesis; visual field, cognitive, and
coordination deficits; and poststroke
seizures. The ability to return to driving
is often viewed by patients as their
metric for return to normalcy and
independence, and inability to return
to driving can affect their ability to
return to work. Consequently, patients
often ask for clearance to return to
driving or ask when they can anticipate
this clearance. A clearance to return to
driving should involve both a medical
clearance and a functional assessment
clearance. The medical clearance evaluation can be performed by a health care
professional; it should ensure that visual field, cognitive, and motor deficits are not severe enough to impact
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249

Stroke Rehabilitation
KEY POINT

h A formal driving
assessment is helpful
in determining a
stroke survivor’s
ability to drive.

driving ability and that seizure control is
compliant with local laws. The medical
clearance evaluation should also assess
other medical comorbidities, such as
cardiac conditions, that could potentially affect the patient’s driving and
lead to harm for the patient or others
on the road. However, more complex
aspects of driving, such as planning,
motor coordination, and reaction
times, are difficult to ascertain in the
office. A formal driving assessment
can be helpful to evaluate these skills
and can be conducted on a driving simulator or by in-car evaluation by a
specialist assessor.
EMERGING TECHNIQUES IN
STROKE REHABILITATION
Further advances in stroke recovery
and rehabilitation will likely occur in
the next decade. On a systems of care
level, telemedicine is currently playing
a role in the acute management of
stroke but will likely expand to the
recovery phase of stroke (telerehabilitation). Telemedicine networks can
be applied to assess and evaluate the
rehabilitation needs of patients at home
or in rural areas where rehabilitation
resources and expertise may not be
readily available. For patients with residual deficits who have exhausted
insurance, telemedicine avenues may
be developed to focus on wellness and
self-training. In a health care system
that stresses evidence-based medicine,
quality metrics, and cost-containment,
rehabilitation strategies that are not only
more clinically effective but also more
cost-effective and efficient are needed.
Research studies are ongoing to
test the viability of interventions such
as novel pharmacologic agents, stem
cells, brain stimulation, and virtual
reality. To better identify candidates
for specific rehabilitation interventions
and tailor treatments to the individual,
biomarkers must be developed.

250

CONCLUSION
Stroke rehabilitation is a complex
process that involves multiple health
care specialties and multiple approaches, depending on the nature
of the patient’s deficits. While the
timing and dosing of therapy and
novel approaches have not been fully
validated and established, it is clear
that successful rehabilitation can make
a positive impact on the outcome of
stroke survivors. Neurologists can play
a role in rehabilitation by advising
patients on the natural history of
stroke, ensuring that the appropriate
therapy and therapy location are
provided, screening for poststroke
depression, and recognizing and managing specific issues in stroke rehabilitation. Stroke rehabilitation is the
next frontier in stroke care, and physicians involved in this field will have
more knowledge and many more tools
at their disposal in the coming years.
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