Physical therapy after stroke

Contents

Stroke

Ischemic stroke is treated by removing obstruction and restoring blood flow to the brain. The only U. S. Food and Drug Administration (FDA)-approved medication for ischemic stroke is tissue plasminogen activator (tPA), which must be administered within a three-hour window from the onset of symptoms to work best. Unfortunately, only 3- 5 percent of those who suffer a stroke reach the hospital in time to be considered for this treatment, and the actual use of tPA is considerably lower. This medication carries a risk for increased intracranial hemorrhage and is not used for hemorrhagic stroke.

Emergency Surgical Stroke Treatment: Neurointerventional Procedures

Microcatheter-based surgical interventions for stroke may include the use of a small microcatheter, delivered through a larger guiding catheter inserted at the groin through a small incision. A microguidewire is used to navigate the microcatheter to the site of obstruction in the brain. Thrombolytic medication, such as tPA, can then be administered directly to the occluding thrombus. This kind of treatment, which delivers thrombolytic medication intraarterially, is more specific than IV (intravenous) tPA and consequently may require significantly lesser dosages of medication. The time limit to implement this type of intervention is also significantly (double) longer than that for IV TPA. Generally, only Comprehensive Stroke Care Centers offer this type of treatment.

Clot Retrieval Devices

The Merci Retriever, approved in 2004 by the FDA, is a corkscrew- shaped device used to help remove blood clots from the arteries of stroke patients. A small incision is made in the patient’s groin, into which a small catheter is fed until it reaches the arteries in the neck. At the neck, a small catheter inside the larger catheter is guided through the arteries into the brain, until it reaches the brain clot. A straight wire inside the small catheter pokes out beyond the clot and automatically coils into a corkscrew shape. It is pulled back into the clot, the corkscrew spinning and grabbing the clot. A balloon inflates in the neck artery, cutting off blood flow, so the device can pull the clot out of the brain safely. The clot is removed through the catheter with a syringe.

Penumbra is also a microcatheter-based system device, which works by an aspiration principle. It was approved by the FDA in 2008.

Stentriever devices are the newest generation of embolectomy devices for stroke. They are still in an investigative phase but work by breaking up the occluding clot, combined with aspiration or withdrawal.

Medical Prevention

Medications used to help prevent stroke in high-risk patients (especially those who have experienced a previous TIA or ischemic stroke) fall into two major categories: anticoagulants and antiplatelet agents.

Anticoagulants thin the blood and prevent clotting. Heparin acts quickly and is given intravenously or subcutaneously (beneath the skin) while a patient is in the hospital. Slower-acting warfarin can be given orally and is used over a longer period. Because these drugs affect the blood’s ability to clot, they require close monitoring by a physician.

Antiplatelet drugs prevent platelet aggregation. Platelets are specialized cells in the blood that initiate a healing process. Large numbers of platelets clump together to form a clot, which can sometimes block an artery or break loose, travel through the bloodstream and block a smaller artery. Antiplatelet drugs make platelets less sticky and less likely to form clots, reducing the risk of ischemic stroke in patients who have had TIA or prior ischemic stroke.

Preventive Surgical Procedures

Carotid Endarterectomy Surgery (Carotid Endarterectomy, CEA)

Patients will be given either a general or local anesthetic before surgery. In this procedure, the neurosurgeon makes an incision in the carotid artery in the neck and removes the plaque using a dissecting tool. Removing the plaque is accomplished by widening the passageway, which helps to restore normal blood flow. The artery will be repaired with sutures or a graft. The entire procedure usually takes about two hours. One may experience pain near the incision in the neck and some difficulty swallowing during the first few days after surgery. Most patients are able to go home after one or two days and return to work usually within a month. Patients should avoid driving and limit physical activities for a few weeks after surgery.

There are potential complications with carotid endarterectomy surgery, just as there are with any type of surgery. There is a 1-3 percent risk of stroke following surgery. Another fairly rare complication is the reblockage of the carotid artery, called restenosis. This may occur later, especially in cigarette smokers. Numbness in the face or tongue caused by temporary nerve damage is a possibility, but uncommon. This usually clears up in less than one month and most often does not require any treatment.

Carotid Angioplasty and Stenting

An alternative, newer form of treatment, carotid angioplasty and stenting (CAS), shows some promise in patients who may be at too high risk to undergo surgery. Carotid stenting is a neurointerventional procedure in which a tiny, slender metal-mesh tube is fitted inside the carotid artery to increase the flow of blood blocked by plaques. Access is gained through a small (0.5 cm) groin incision, but no incision is made in the neck. The stent is inserted following a procedure called angioplasty, in which the doctor guides a balloon-tipped catheter into the blocked artery. The balloon is inflated and pressed against the plaque, flattening it and reopening the artery. The stent acts as scaffolding to prevent the artery from collapsing or from closing up again after the procedure is completed.

There are several potential complications of endovascular treatment. The most serious risk from carotid stenting is an embolism caused by a disrupted plaque particle breaking free from the site. This can block an artery in the brain, causing a stroke. These risks are minimized using small filters called embolic protection devices in conjunction with angioplasty and stenting. There is also a slight risk of stroke due to a loose piece of plaque or a blood clot blocking an artery during or right after surgery. The risks are balanced against the advantages of a shorter occlusion time (10 seconds, as opposed to 30 minutes for endarterectomy), shorter anesthesia and a small leg incision.

Hyperperfusion, or the sudden increased blood flow through a previously blocked carotid artery and into the arteries of the brain, can cause a hemorrhagic stroke. Other complications include restenosis and short periods of medically treatable reduced blood pressure and heart rate. These risks are similar for CEA and CAS.

Hemorrhagic Stroke Treatment

Hemorrhagic stroke usually requires surgery to relieve intracranial (within the skull) pressure caused by bleeding. Surgical treatment for hemorrhagic stroke caused by an aneurysm or defective blood vessel can prevent additional strokes. Surgery may be performed to seal off the defective blood vessel and redirect blood flow to other vessels that supply blood to the same region of the brain.

For a patient with a ruptured cerebral aneurysm, surgical elimination of the aneurysm is only the beginning. Intensive care recovery for the next 10-14 days is the rule, during which time a multitude of complications related to subarachnoid hemorrhage (SAH) can and do occur. At some time during that period (often immediately upon completion of surgery), cerebral angiography or a substitute study is done to document that the aneurysm has been eliminated. The first two to five days after SAH represent the greatest threat of brain swelling; at which time special measures (both medical and surgical) are used to diminish the effect of swelling on intracranial pressure. Near the end of this initial period, the risk period for delayed cerebral vasospasm begins and lasts the better part of the next 14 days. Intercurrent infections such as pneumonia are common, and hydrocephalus may develop.

Surgery/Clipping

Prior to surgery, the exact location of the subarachnoid hemorrhage or aneursym is identified through cerebral angiography images. An operation to “clip” the aneurysm is performed by doing a craniotomy (opening the skull surgically) and isolating the aneurysm from the normal bloodstream. In addition, a craniectomy, a surgical procedure in which part of the skull is removed and left off temporarily, may be done to help relieve increased intracranial pressure.

One or more tiny titanium clips with spring mechanisms are applied to the base of the aneurysm, allowing it to deflate. The size and shape of the clips is selected based on the size and location of the aneurysm. Clips are permanent, remain in place and generally provide a durable cure for the patient. Angiography is used to confirm exclusion of the aneurysm from the cerebral circulation and the preservation of normal flow of blood in the brain.

Endovascular (Neurointerventional) Treatment

Neurointerventional procedures for cerebral aneurysm share the advantages of no incision made in the skull and an anesthesia time that is often dramatically shorter than for craniotomy and microsurgical clipping.

In endovascular microcoil embolization, a needle is placed into the femoral artery of the leg, and a small catheter is inserted. Utilizing x-ray guidance, the catheter is advanced through the body’s arterial system to one of the four blood vessels that feed the brain. A smaller microcatheter is fed into the aneurysm, and once properly positioned, a thin wire filament or “coil” is advanced into the aneurysm. The flexible, platinum coil is designed to conform to the shape of the aneurysm. Additional coils are advanced into the aneurysm to close the aneurysm from the inside. This prevents flow of blood into the aneurysm by causing a clot to form on the inside.

Balloon-assisted coiling uses a tiny balloon catheter to help hold the coil in place. Although this has been shown in several studies to increase risks, ongoing innovations in this relatively new technology has helped improve its efficacy. Combination stent and coiling utilizes a small flexible cylindrical mesh tube that provides a scaffold for the coiling. Intracranial stenting and other innovations are quite new, and endovascular technology is in a constant state of development. These adjuncts allow coiling to be considered for cerebral aneurysms that may not have an ideal shape for conventional coiling.

Stroke Rehabilitation

Recovery and rehabilitation are among the most important aspects of stroke treatment. As a rule, most strokes are associated with some recovery, the extent of which is variable. In some cases, undamaged areas of the brain may be able to perform functions that were lost when the stroke occurred. Rehabilitation includes physical therapy, speech therapy and occupational therapy. This type of recovery is measured in months to years.

  • Physical therapy involves using exercise and other physical means (e.g., massage, heat) and may help patients regain the use of their arms and legs and prevent muscle stiffness in patients with permanent paralysis.
  • Speech therapy may help patients regain the ability to speak.
  • Occupational therapy may help patients regain independent function and relearn basic skills (e.g., getting dressed, preparing a meal and bathing).

Conclusion

Modern treatments for ischemic and hemorrhagic stroke have reached an advanced state of development in the modern era of digital and device technology. Neurointerventional treatments enable surgical procedures in the brain without the need to open the skull surgically and provide excellent treatment alternatives for all forms of stroke and cerebrovascular disease. These developments are timely, occurring in an era when stroke incidence is on the rise as the population ages.

The AANS does not endorse any treatments, procedures, products or physicians referenced in these patient fact sheets. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific neurosurgical advice or assistance should consult his or her neurosurgeon, or locate one in your area through the AANS’ Find a Board-certified Neurosurgeon online tool.

Stroke

What is a stroke?

A stroke happens when there is a loss of blood flow to part of the brain. Your brain cells cannot get the oxygen and nutrients they need from blood, and they start to die within a few minutes. This can cause lasting brain damage, long-term disability, or even death.

If you think that you or someone else is having a stroke, call 911 right away. Immediate treatment may save someone’s life and increase the chances for successful rehabilitation and recovery.

What are the types of stroke?

There are two types of stroke:

  • Ischemic stroke is caused by a blood clot that blocks or plugs a blood vessel in the brain. This is the most common type; about 80 percent of strokes are ischemic.
  • Hemorrhagic stroke is caused by a blood vessel that breaks and bleeds into the brain

Another condition that’s similar to a stroke is a transient ischemic attack (TIA). It’s sometimes called a “mini-stroke.” TIAs happen when the blood supply to the brain is blocked for a short time. The damage to the brain cells isn’t permanent, but if you have had a TIA, you are at a much higher risk of having a stroke.

Who is at risk for a stroke?

Certain factors can raise your risk of a stroke. The major risk factors include

  • High blood pressure. This is the primary risk factor for a stroke.
  • Diabetes.
  • Heart diseases. Atrial fibrillation and other heart diseases can cause blood clots that lead to stroke.
  • Smoking. When you smoke, you damage your blood vessels and raise your blood pressure.
  • A personal or family history of stroke or TIA.
  • Age. Your risk of stroke increases as you get older.
  • Race and ethnicity. African Americans have a higher risk of stroke.

There are also other factors that are linked to a higher risk of stroke, such as

  • Alcohol and illegal drug use
  • Not getting enough physical activity
  • High cholesterol
  • Unhealthy diet
  • Having obesity

What are the symptoms of stroke?

The symptoms of stroke often happen quickly. They include

  • Sudden numbness or weakness of the face, arm, or leg (especially on one side of the body)
  • Sudden confusion, trouble speaking, or understanding speech
  • Sudden trouble seeing in one or both eyes
  • Sudden difficulty walking, dizziness, loss of balance or coordination
  • Sudden severe headache with no known cause

If you think that you or someone else is having a stroke, call 911 right away.

How are strokes diagnosed?

To make a diagnosis, your health care provider will

  • Ask about your symptoms and medical history
  • Do a physical exam, including a check of
    • Your mental alertness
    • Your coordination and balance
    • Any numbness or weakness in your face, arms, and legs
    • Any trouble speaking and seeing clearly
  • Run some tests, which may include
    • Diagnostic imaging of the brain, such as a CT scan or MRI
    • Heart tests, which can help detect heart problems or blood clots that may have led to a stroke. Possible tests include an electrocardiogram (EKG) and an echocardiography.

What are the treatments for stroke?

Treatments for stroke include medicines, surgery, and rehabilitation. Which treatments you get depend on the type of stroke and the stage of treatment. The different stages are

  • Acute treatment, to try to stop a stroke while it is happening
  • Post-stroke rehabilitation, to overcome the disabilities caused by the stroke
  • Prevention, to prevent a first stroke or, if you have already had one, prevent another stroke

Acute treatments for ischemic stroke are usually medicines:

  • You may get tPA, (tissue plasminogen activator), a medicine to dissolve the blood clot. You can only get this medicine within 4 hours of when your symptoms started. The sooner you can get it, the better your chance of recovery.
  • If you cannot get that medicine, you may get medicine that helps stop platelets from clumping together to form blood clots. Or you may get a blood thinner to keep existing clots from getting bigger.
  • If you have carotid artery disease, you may also need a procedure to open your blocked carotid artery

Acute treatments for hemorrhagic stroke focus on stopping the bleeding. The first step is to find the cause of bleeding in the brain. The next step is to control it:

  • If high blood pressure is the cause of bleeding, you may be given blood pressure medicines.
  • If an aneurysm if the cause, you may need aneurysm clipping or coil embolization. These are surgeries to prevent further leaking of blood from the aneurysm. It also can help prevent the aneurysm from bursting again.
  • If an arteriovenous malformation (AVM) is the cause of a stroke, you may need an AVM repair. An AVM is a tangle of faulty arteries and veins that can rupture within the brain. An AVM repair may be done through
    • Surgery
    • Injecting a substance into the blood vessels of the AVM to block blood flow
    • Radiation to shrink the blood vessels of the AVM

Stroke rehabilitation can help you relearn skills you lost because of the damage. The goal is to help you become as independent as possible and to have the best possible quality of life.

Prevention of another stroke is also important, since having a stroke increases the risk of getting another one. Prevention may include heart-healthy lifestyle changes and medicines.

Can strokes be prevented?

If you have already had a stroke or are at risk of having a stroke, you can make some heart-healthy lifestyle changes to try to prevent a future stroke:

  • Eating a heart-healthy diet
  • Aiming for a healthy weight
  • Managing stress
  • Getting regular physical activity
  • Quitting smoking
  • Managing your blood pressure and cholesterol levels

If these changes aren’t enough, you may need medicine to control your risk factors.

NIH: National Institute of Neurological Disorders and Stroke

Stroke

A stroke is serious, just like a heart attack, so it’s important to know the signs of stroke and act quickly if you suspect someone is having one. Stroke is the fourth leading cause of death in the United States, and causes more serious long-term disabilities than any other disease. Older people are at higher risk. You can take steps to lower your chance of having a stroke.

What Is a Stroke?

A stroke happens when something changes how blood flows through the brain. Blood brings oxygen and nutrients to brain cells. If blood can’t flow to a part of the brain, cells that do not receive enough oxygen suffer and eventually die. If brain cells are without oxygen for only a short time, they can sometimes get better. But brain cells that have died can’t be brought back to life. So, someone who has had a stroke may have trouble speaking, thinking, or walking.

There are two major types of stroke. The most common kind, ischemic, is caused by a blood clot or the narrowing of a blood vessel (an artery) leading to the brain. This keeps blood from flowing into other parts of the brain and keeps needed oxygen and nutrients from reaching brain cells. Blockages that cause ischemic strokes stem from three conditions:

  • Formation of a clot within a blood vessel of the brain or neck, called thrombosis
  • Movement of a clot from another part of the body, such as from the heart to the neck or brain, called an embolism
  • Severe narrowing of an artery (stenosis) in or leading to the brain, due to fatty deposits lining the blood vessel walls

In the second major kind of stroke, hemorrhagic, a broken blood vessel causes bleeding in the brain. This break in the vessel also stops oxygen and nutrients from reaching brain cells.

Sometimes the symptoms of a stroke last only a few minutes and then go away. That could be a transient ischemic attack (TIA), also called a mini-stroke. A TIA is a medical emergency. You should get medical help right away. If a TIA is not treated quickly, it could be followed within hours or days by a major disabling stroke.

Lower Your Risk of Stroke

Some risk factors for stroke, like age, race, and family history, can’t be controlled. But you can make changes to lower your risk of stroke. Talk to your doctor about what you can do. Even if you’re in perfect health, follow these suggestions:

  • Control your blood pressure. Have your blood pressure checked often. If it is high, follow your doctor’s advice to lower it. Treating high blood pressure lowers the risk of both stroke and heart disease.
  • Stop smoking. Smoking increases your risk for stroke. It’s never too late to quit.
  • Control your cholesterol. If you have high cholesterol, work with your doctor to lower it. Cholesterol, a type of fat in the blood, can build up on the walls of your arteries. In time, this can block blood flow and lead to a stroke.
  • Control your diabetes. Untreated diabetes can damage blood vessels and also leads to narrowed arteries and stroke. Follow your doctor’s suggestions for keeping diabetes under control.
  • Eat healthy foods. Eat foods that are low in cholesterol and saturated fats. Include a variety of fruits and vegetables every day.
  • Exercise regularly. Try to make physical activity a part of your everyday life. Do things you like; for example, take a brisk walk, ride a bicycle, or go swimming. Talk with your healthcare provider if you haven’t been exercising and you want to start a vigorous program or increase your physical activity. For more information on exercise and physical activity from the National Institute on Aging at NIH, visit the Go4Life website.

If you have had a stroke in the past, it’s important to reduce your risk of a second stroke. Your brain helps you recover from a stroke by drawing on body systems that now do double duty. That means a second stroke can be twice as bad.

Diagnosing and Treating Stroke

A doctor will diagnose a stroke based on symptoms, medical history, and medical tests such as a CT scan. A CT scan is a test that lets doctors look closely at pictures of the brain.

All strokes benefit from immediate medical treatment! But only people with ischemic stroke, the kind caused by a blood clot, can be helped by a drug called t-PA (tissue-plasminogen activator). This drug breaks up blood clots and can greatly lessen the damage caused by an ischemic stroke. Starting treatment with t-PA within 3 hours after an ischemic stroke is important to recovery. To be evaluated and receive treatment, patients need to get to the hospital within 60 minutes. Getting to a hospital right away allows time for a CT scan of the brain. This scan will show whether the clot-busting medicine is the right treatment choice.

With stroke, treatment depends on the stage of the disease. There are three treatment stages for stroke: prevention, therapy immediately after stroke, and rehabilitation after stroke. Stroke therapies include medications, surgery, and rehabilitation.

Medication or drug therapy is the most common treatment for stroke. The most popular kinds of drugs to prevent or treat stroke are antithrombotics–which include antiplatelet agents and anticoagulants–and thrombolytics. Thrombolytic drugs, like t-PA, halt the stroke by dissolving the blood clot that is blocking blood flow to the brain. Antithrombotics prevent the formation of blood clots that can become stuck in an artery of the brain and cause strokes.

Surgery and vascular procedures can be used to prevent stroke, treat stroke, or repair damage to the blood vessels or malformations in and around the brain. These include angioplasty, stenting, and carotid endarterectomy.

What Happens After a Stroke?

A stroke can cause a variety of health problems. How a stroke affects a person depends on which part of the brain is damaged.

Someone who has had a stroke might be paralyzed or have weakness, usually on one side of the body. He or she might have trouble speaking or using words. There could be swallowing problems. There might be pain or numbness.

Stroke may cause problems with thinking, awareness, attention, learning, judgment, and memory. Someone who has had a stroke might feel depressed or find it hard to control emotions. Post-stroke depression may be more than general sadness resulting from the stroke incident. It is a serious behavioral problem that can hamper recovery and rehabilitation and may even lead to suicide.

There are many different ways to help people get better after a stroke. Many treatments start in the hospital and continue at home. Drugs and physical therapy can help improve balance, coordination, and problems such as trouble speaking and using words. Occupational therapy can make it easier to do things like taking a bath or cooking.

Some people make a full recovery soon after a stroke. Others take months or even years. But, sometimes the damage is so serious that therapy cannot really help.

Learn about rehabilitation after stroke.

For More Information on Stroke

MedlinePlus
National Library of Medicine

National Stroke Association
1-800-787-6537 (toll-free)
[email protected]

This content is provided by the National Institute on Aging (NIA), part of the National Institutes of Health. NIA scientists and other experts review this content to ensure that it is accurate, authoritative, and up to date.

Content reviewed: May 16, 2017

Rehabilitation After Stroke

Stroke is the number one cause of serious adult disability in the United States. Stroke disability is devastating to the stroke patient and family, but therapies are available to help rehabilitate patients after stroke.

For most stroke patients, rehabilitation mainly involves physical therapy. The aim of physical therapy is to have the stroke patient relearn simple motor activities such as walking, sitting, standing, lying down, and the process of switching from one type of movement to another.

Another type of therapy to help patients relearn daily activities is occupational therapy. This type of therapy also involves exercise and training. Its goal is to help the stroke patient relearn everyday activities such as eating, drinking and swallowing, dressing, bathing, cooking, reading and writing, and using the toilet. Occupational therapists seek to help the patient become independent or semi-independent.

Speech therapy helps stroke patients relearn language and speaking skills, or learn other forms of communication. Speech therapy is appropriate for patients who have no problems with cognition or thinking, but have problems understanding speech or written words, or problems forming speech. With time and patience, a stroke survivor should be able to regain some, and sometimes all, language and speaking abilities.

Learn more about stroke signs, treatment, and prevention from the Centers for Disease Control and Prevention.

Physiotherapy after stroke

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Mobility and exercise after stroke fact sheet

What you need to know

  • A stroke can affect how well you sit, move, balance, stand and walk.
  • Your physiotherapist will work with you to set goals and develop a rehabilitation program to meet your needs.
  • Exercise will improve your fitness, your general health and reduce your risk of having another stroke.

How a stroke can affect mobility

After a stroke, you may experience:

Weakness. Your foot and leg may be paralysed completely or they may be weak. Paralysis on one side of the body is called hemiplegia. Weakness on one side of the body is called hemiparesis.

Planning or coordinating problems. You may have difficulty planning leg movements. This is called apraxia. You may also have difficulty coordinating movements which makes them feel slow or clumsy. This is called ataxia.

Changes in the muscles. You may have high tone which makes your muscles stiff and tight. This is called hypertonia or spasticity. Alternatively, your muscles may be floppy or loose. This is called low tone or hypotonia.

Balance. You may have difficulty keeping your balance, feel unsteady or dizzy.

Contracture. If your muscles are tight or weak, they can become shorter. This can result in the joint becoming fixed in one position.

Changes in sensation. You might lose feeling, have pins and needles or have increased feeling (hypersensitivity).

Swelling. If your leg or foot does not move as well as it used to, fluid may build up (oedema).

Fatigue. You may feel very tired after walking even a short distance. This is made worse because as you may have to concentrate hard on even simplest movements.

Pain. You may experience pain in your leg after a stroke, most often in the hip. This can make walking more difficult.

Treatment and recovery

Mobility difficulties affect everyone differently. Your physiotherapist will assess how well you move, sit, stand and walk. They will then work with you to set goals and develop a rehabilitation program to meet your needs.

Your rehabilitation will focus on your specific difficulties. You may need to relearn how to:

  • Roll over in bed.
  • Move from sitting to standing.
  • Move from a bed to a chair or a toilet (transferring).
  • Walk.

Exercises

Specifically prescribed exercises can improve your strength, coordination, balance, sensation or fitness. Often this can be done during daily activities such as standing or walking. This is known as task-specific activity and is the most effective way to improve.

Repetition is key to improvement, so you may do movements many times. Movement and exercises can help to reduce muscle stiffness and pain.

Electrical stimulation may be used to strengthen weak muscles. Equipment such as treadmills may also be used as part of your rehabilitation program. Your therapist may also recommend video games to help you practice.

Weakness and contracture can cause ‘foot drop’. This is when the foot or ankle drops down when you lift your leg to take a step.
A plastic brace known as an ankle-foot orthosis (AFO) may be used for foot drop. These braces support the foot and ankle to help minimise tripping and reduce fall risks.

While you may make the most improvement in the first six months, regular activity will help you to continue your recovery. If you have been experiencing fatigue, depression or pain since your stroke regular exercise may help. Exercise improves your fitness, your general health and reduces your risk of having another stroke.

You could join a fitness centre or an exercise group at your local community health centre. Talk to your doctor or physiotherapist before beginning or changing an exercise program.

Falls

After a stroke, you may be at increased risk of falling. Wear comfortable, firm-fitting, flat shoes with a low broad heel and soles that grip. Don’t wear poorly fitted slippers or walk in socks.

Your therapists can assess how safe you are in different situations, such as going up and down stairs and walking outdoors. Your physiotherapist may advise you to use a walking frame, stick or wheelchair, and will make sure you are using it safely. Your occupational therapist may assess your home for hazards and suggest equipment to prevent falls, such as a handrail or shower chair.

More help

The health professionals at StrokeLine provide information, advice, support and referral. StrokeLine’s practical and confidential advice will help you manage your health better and live well.
Call 1800 STROKE (1800 787 653)
Email [email protected]

Join Australia’s online stroke community with videos, fact sheets, resources and support for stroke survivors, their family and friends.
enableme.org.au

Find a physiotherapist:
Australian Physiotherapy Association
03 9092 0888 www.physiotherapy.asn.au

Find an occupational therapist:
Occupational Therapy Australia
1300 682 878 www.otaus.com.au

Download the Mobility and exercise after stroke fact sheet (PDF 859 KB)

For more information visit the EnableMe resource topics on Exercise, Arm and hand function and Leg functioning.

Stroke is the No. 5 killer of all Americans and a leading cause of long-term adult disability, affecting more than 795,000 people a year. Few are prepared for this sudden, often catastrophic event, but rehabilitation rates are encouraging. In some cases, brain cell damage may be temporary and may resume functioning over time. In other cases, the brain can reorganize its own functioning and a region of the brain “takes over” for a region damaged by the stroke.

Here is some general guidance on recovery:

  • Ten percent of stroke survivors recover almost completely. Another 10 percent require care in a nursing home or other long-term care facility.
  • One-quarter percent recover with minor impairments.
  • Forty percent experience moderate to severe impairments.

Rehabilitation

The long-term goal of rehabilitation is to help the stroke survivor become as independent as possible. Ideally this is done in a way that preserves dignity and motivates the survivor to relearn basic skills like bathing, eating, dressing and walking. Rehabilitation typically starts in the hospital after a stroke. If your condition is stable, rehabilitation can begin within two days of the stroke and continue after your release from the hospital. The best option often depends on the severity of the stroke:

  • A rehabilitation unit in the hospital with inpatient therapy
  • A subacute care unit
  • A rehabilitation hospital with individualized inpatient therapy
  • Home therapy
  • Returning home with outpatient therapy
  • A long-term care facility that provides therapy and skilled nursing care

Your recovery team

A team of professionals will plan your rehab program to help you meet your stroke recovery goals. This team may include some of the following:

Physiatrist – specializes in rehabilitation following injuries, accidents or illness.

Neurologist – specializes in the prevention, diagnosis and treatment of stroke and other diseases of the brain and spinal cord.

Rehabilitation nurse – helps people with disabilities and helps survivors manage health problems like diabetes and high blood pressure and adjust to life after stroke.

Physical therapist – helps with problems in moving and balance, suggesting exercises to strengthen muscles for walking, standing and other activities.

Occupational therapist – helps with strategies to manage daily activities such as eating, bathing, dressing, writing and cooking.

Speech-language pathologist – helps with talking, reading and writing, and shares strategies to help with swallowing problems.

Dietician – teaches survivors about healthy eating and special diets low in sodium, fat and calories.

Social worker – helps survivors make decisions about rehab programs, living arrangements, insurance and home support services.

Neuropsychologist – diagnoses and treats survivors who face changes in thinking, memory and behavior.

Case manager – helps survivors facilitate follow-up to acute care, coordinate care from multiple providers and link to local services.

Recreation Therapist. Helps with strategies to improve the thinking and movement skills needed to join in recreational activities

Stroke Treatment

If you get to the hospital within 3 hours of the first symptoms of an ischemic stroke, you may get a type of medicine called a thrombolytic (a “clot-busting” drug) to break up blood clots. Tissue plasminogen activator (tPA) is a thrombolytic.

tPA improves the chances of recovering from a stroke. Studies show that patients with ischemic strokes who receive tPA are more likely to recover fully or have less disability than patients who do not receive the drug.2,3 Patients treated with tPA are also less likely to need long-term care in a nursing home.4 Unfortunately, many stroke victims don’t get to the hospital in time for tPA treatment. This is why it’s so important to recognize the signs and symptoms of stroke right away and call 9-1-1.

Medicine, surgery, or other procedures may be needed to stop the bleeding and save brain tissue. For example:

  • Endovascular procedures. Endovascular procedures may be used to treat certain hemorrhagic strokes. The doctor inserts a long tube through a major artery in the leg or arm and then guides the tube to the site of the weak spot or break in a blood vessel. The tube is then used to install a device, such as a coil, to repair the damage or prevent bleeding.
  • Surgical treatment. Hemorrhagic strokes may be treated with surgery. If the bleeding is caused by a ruptured aneurysm, a metal clip may be put in place to stop the blood loss.

What Happens Next

If you have had a stroke, you are at high risk for another stroke:

  • 1 of 4 stroke survivors has another stroke within 5 years.5
  • The risk of stroke within 90 days of a TIA may be as high as 17%, with the greatest risk during the first week.6

That’s why it’s important to treat the underlying causes of stroke, including heart disease, high blood pressure, atrial fibrillation (fast, irregular heartbeat), high cholesterol, and diabetes. Your doctor may give you medications or tell you to change your diet, exercise, or adopt other healthy lifestyle habits. Surgery may also be helpful in some cases.

Stroke Rehabilitation

After a stroke, you may need rehabilitation (rehab) to help you recover. Before you are discharged from the hospital, social workers can help you find care services and caregiver support to continue your long-term recovery. It is important to work with your health care team to find out the reasons for your stroke and take steps to prevent another stroke.

Learn more about recovering from stroke.

More Information

From CDC:

  • Stroke
  • Signs and Symptoms of Stroke
  • Heart Attack

From other organizations:

  • What You Need to Know About Strokeexternal icon–National Institute of Neurological Disorders and Stroke
  • Know Stroke: Know the Signs. Act in Time.external icon–National Institutes of Health
  • Mind Your Risksexternal icon–National Institutes of Health
  • Strokeexternal icon–Medline Plus
  • Brain Health Resource Pageexternal icon–American Heart Association/American Stroke Association
  • Internet Stroke Centerexternal icon
  • Stroke warning signs quiz (Englishexternal icon and Spanishexternal icon)–American Heart Association/American Stroke Association
  • What to Expect at the Hospitalexternal icon–National Stroke Association
  1. Ekundayo OJ, Saver JL, Fonarow GC, Schwamm LH, Xian Y, Zhao X, et al. Patterns of emergency medical services use and its association with timely stroke treatment: findings from Get With the Guidelines-Strokeexternal icon. Circulation: Cardiovascular Quality and Outcomes. 2013;6:262-269.
  2. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333(24):1581–7.
  3. Marler JR, Tilley BC, Lu M, Brott TG, Lyden PC, Grotta JC, et al. Early stroke treatment associated with better stroke outcome: the NINDS rt-PA stroke study. Neurology 2000;55(11):1649–55.
  4. National Institute of Neurological Disorders and Stroke. (2009). Stroke: challenges, progress, and promiseexternal icon. Bethesda, MD: National Institutes of Health.
  5. American Heart Association (AHA), Heart Disease and Stroke Statistics – 2010 Update. http://circ.ahajournals.org/content/121/7/e46#sec-23external icon.
  6. Lambert M. Practice Guidelines: AHA/ASA guidelines on prevention of recurrent stroke. Am Fam Physician 2011;83(8):993–1001.

Tips for Stroke Treatment and Rehabilitation

Stroke rehabilitation may involve occupational therapy. Getty Images

Treatments for stroke vary depending on whether the stroke is caused by a blood clot (ischemic stroke) or a brain bleed (hemorrhagic stroke).

No matter the type of stroke, acting fast and seeking treatment as quickly as possible is key to reducing the risk of permanent brain damage.

Treatment for Ischemic Stroke

Ischemic strokes happen when a blood clot in an artery blocks the flow of blood and oxygen to a portion of the brain.

With this type of stroke, the goal is to restore blood flow to the brain as quickly as possible.

In most cases, medication is given at the hospital to help break up the clot and prevent the formation of new clots.

These drugs may include:

Tissue Plasminogen Activator (tPA, Alteplase) Alteplase or tPA is a thrombolytic medication, often referred to as a “clot buster,” which is the gold standard for treating ischemic stroke.

This drug must be started within a few hours after stroke symptoms first appear. It will quickly break up or dissolve blood clots that are blocking blood flow to the brain.

This type of medicine is given through a catheter or IV tube in the arm. (1)

Aspirin Aspirin won’t dissolve existing blood clots, but it will help to prevent new clots from forming.

Doctors may give aspirin within 48 hours of the start of stroke symptoms. Importantly, the American Heart Association advises not to take aspirin before talking to your doctor. This is because while most strokes are caused by blood clots, not all of them are. Some strokes are caused by ruptured blood vessels, and taking aspirin could potentially make these strokes more severe.

Your healthcare provider will be able to tell you if you are a candidate for aspirin therapy. (2)

Nonmedication treatments for ischemic stroke include mechanical thrombectomy. This endovascular procedure attempts to remove a large blood clot. A trained doctor will insert a wire-caged device (called a stent retriever) through a catheter inserted in the groin to the site of the blocked blood vessel in the brain. The stent then opens and grabs the clot, allowing the doctor to remove the stent along with the trapped clot. (3)

Treatment for Hemorrhagic Stroke

Hemorrhagic strokes happen when blood vessels in or around the brain rupture or leak.

This puts too much pressure on the surrounding brain tissue, cutting off circulation and starving the brain of oxygen.

Treatment for hemorrhagic stroke will depend on the cause of the bleeding and what part of the brain is affected.

Bleeding around the brain is often caused by abnormally formed blood vessels, called arteriovenous malformations (AVMs), and swelling within the vessels, called aneurysms.

Bleeding in the brain is often caused by high blood pressure.

Nonsurgical treatments for hemorrhagic stroke may include:

  • Controlling blood pressure
  • Stopping any medication that could increase bleeding (such as warfarin and aspirin)
  • Blood transfusions with blood clotting factors to stop ongoing bleeding (1)

Other treatments for hemorrhagic stroke may include:

  • Endovascular Procedure A long tube is slid into a blood vessel in an arm or leg, and passed all the way up to the blood vessels in the brain, where a coil or clip is placed to prevent further bleeding. (4)
  • Surgical Clipping To treat an aneurysm, a surgeon may place a tiny clamp at its base to stop the blood from flowing.
  • Surgical AVM Removal If an AVM is located in an accessible area of the brain, a surgeon may remove it to eliminate the risk of rupture. But this is not always possible, especially if the AVM is too large or is located deep within the brain.
  • Stereotactic Radiosurgery This is an advanced, minimally invasive technique that uses highly focused radiation to repair vascular malformations. (1)

$ Things That Might Help Rehabilitation

Brain injury due to stroke can change the way you move, feel, think, or speak. The effects are greatest right after the stroke.

Over time, most people will make improvements.

Stroke rehabilitation programs can help, though these programs will not “cure” or reverse brain damage.

The goals of stroke rehabilitation are to help stroke survivors live as independently as possible while adjusting to new limitations.

Rehabilitation usually starts in the hospital, within a day or two of the stroke. Stroke rehabilitation may continue for months or even years after leaving the hospital.

The types of therapy will depend on what parts of the brain were damaged during the stroke.

Stroke survivors may require:

  • Speech therapy
  • Physical therapy and strength training
  • Occupational therapy (relearning skills required for daily living)
  • Psychological counseling

1. Speech Therapy

Stroke survivors may have trouble speaking, finding words, or understanding what other people are saying. This is called aphasia.

Speech-language pathologists help people with aphasia relearn how to use language and communicate.

Therapy may include repeating words as well as reading and writing exercises.

2. Physical Therapy

Stroke can cause problems with movement. Paralysis, or loss of muscle function, is common after stroke — especially on one side of the body.

Physical therapy can help stroke survivors regain strength, coordination, balance, and control of movement.

3. Occupational Therapy

Occupational therapists or rehabilitation nurses can help stroke survivors relearn some of the skills they will need to care for themselves after a stroke.

Rehabilitation nurses may help stroke survivors manage their personal care, such as bathing and washing.

They can also help with therapy to regain continence (control of bladder and bowel movements) after a stroke.

Occupational therapists may help stroke survivors relearn how to do activities such as preparing meals, cleaning the house, and driving. (5)

4. Psychological Counseling

Stroke can cause chemical changes in the brain that affect the way a person thinks, feels, and behaves.

At the same time, stroke rehabilitation can be a long and difficult process.

Even after rehabilitation is complete, most stroke survivors will live with some minor to moderate disabilities.

Many stroke survivors will require mental health counseling and medication to help address issues such as depression, anxiety, frustration, and anger.

It’s important to identify and treat mental health issues, such as depression, early in the recovery process.

Stroke survivors that are depressed may be less likely to follow through with stroke rehabilitation and treatment plans. (6)

Where Can a Stroke Patient Get Rehab?

Before you leave the hospital, a hospital social worker will meet with you and your family to assess what type of rehabilitation programs and living situation you will need while recovering from a stroke.

Some common types of stroke programs and facilities include:

  • Inpatient or nursing facilities (These facilities provide 24-hour rehabilitation and care.)
  • Outpatient facilities (Patients often spend several hours a day at a facility for rehabilitation activities but return home at night.)
  • Home-based programs (Therapists come into the home.) (7)

Additional reporting by Ashley Welch.

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Ischemic Stroke Treatment

The type of therapy administered depends on many factors, including age and general physical health as well as the severity and location of the stroke. The main goal of ischemic stroke therapies is to remove the blockage in the brain.

Emergency Therapies

Thrombolytic agent

  • This clot-busting medication helps dissolve the blood clot that is blocking a cerebral vessel. This will help restore the blood flow in the brain.
  • It is also known as tissue plasminogen activator (t-PA).
  • t-PA is not safe for everyone and must be administered as soon as possible after the start of stroke symptoms.

Neuro-protective agents

  • These medications minimize the damage caused by brain cell death associated with stroke.

Preventative and /or Maintenance Medications

Anticoagulants / Antiplatelets

  • Anticoagulants (e.g., warfarin) and antiplatelets (e.g., aspirin) may be prescribed.
  • These medications hinder the blood’s ability to clot.
  • Other medications may be given in order to relieve pain, increase blood flow, control seizures, and reduce fever and blood sugar levels.

Surgical Therapies

The type of surgery recommended by your physician depends on various factors. Some surgical methodologies include:

Carotid Endarterectomy

  • This surgery involves removing plaque from the carotid artery that leads to the blood flow within the brain.
  • This may reduce the risk of ischemic stroke.

Microsurgical Techniques: Brain Bypass Surgery

  • This microsurgery creates a new path for blood to flow through the brain, particularly in areas that have been depleted of blood.
  • Another vessel usually is grafted to the cerebral artery to create this new path.
  • Microsurgical techniques allow Emory’s experienced neurosurgeons to perform with optimal precision, resulting in less risk and better outcomes for the patient.

Endovascular Procedures (Interventional Neuroradiology)

  • Interventional neuroradiological procedures are a less-invasive means of treating neurovascular disorders.
  • They use very small catheters, called microcatheters, to treat problems inside blood vessels.
  • The microcatheter is inserted into the vessels through a tiny puncture in the groin, where an interventional neuroradiologist can reach almost any vessel in the brain or spinal cord.
  • These endovascular approaches can be used to open narrowed or blocked arteries, dissolve clots in brain arteries, repair certain aneurysms, and close abnormal blood vessels that are at risk of bleeding.
  • These methods often avoid the need for more invasive surgery.

  • Learn more about Interventional Neuroradiology here

Endovascular Thrombolysis

  • In this procedure, a neuro-interventionist threads a microcatheter from an artery in the groin to a blocked artery in the brain.
  • Clot-busting medications are injected into the artery to dissolve the clot and restore blood flow to the brain faster than many other medications.

Cerebral Angioplasty and Stenting

  • This procedure helps widen a blocked artery.
  • A catheter with a balloon at the end is inserted into the obstructed artery and the balloon is inflated, pushing the plaque against the walls.
  • A stent, or a mesh steel brace, then is inserted to keep fatty buildup from clogging the vessel.

Continuing Care

After emergency treatment for hemorrhagic stroke, your physician will likely recommend:

  • Ongoing stroke therapies, including medications, surgery, and interventional neuroradiology
  • Rehabilitation to help regain abilities
  • Follow-up outpatient visits to monitor health
  • Diagnostic procedures if there are signs of additional problems
  • Long-term care to help prevent another stroke
  • Neurointensive/neurocritical care for emergencies
  • Clinical trials for new experimental therapies

Time-sensitive therapies

If treated within three hours, clot-busting medications can reduce the risk of long-term disability.

Stroke Podcasts

Find out more about interventional neuroradiology and Emory’s nationally renowned Neurosciences. .

Time and Experience

Emory’s Stroke Center includes three of the region’s most experienced interventional neuroradiologists. They perform more neuroradiological procedures combined than any other team in the Southeast. Learn more about them here.

What is a stroke?

Do you or someone you care for need treatment?
Find a Physio

A stroke is a sudden ‘brain attack’ that occurs when the blood flow to part of the brain is cut off. Usually, this is due to a blood clot.

Stroke is more common in men and in people over 55, although it can occur at any age. A family history may increase the risk, as can lifestyle factors such as diet, drinking alcohol, smoking and lack of exercise, but sometimes there is no obvious cause.

How can physiotherapy help stroke patients?

The evidence

Read our evidence briefing:

Physiotherapy works: Stroke

Effective treatment can help you recover as well as possible from your stroke.

Physiotherapists play a key role in your healthcare team while you are in hospital and afterwards. The healthcare team will provide you with a rehabilitation programme to help you become as mobile and as independent as possible. As part of your rehabilitation, your physio will provide treatment tailored to your specific needs.

Depending on the severity of the stroke, physiotherapy can help you with getting your muscle control and strength back.

A physio may also work with continence nurses to help you with bladder control, if that is a problem for you.

They will support you and those around you throughout your rehabilitation, to get you back to your everyday life as well as you are able.

Physiotherapy has been shown to work through clinical studies and research and is a treatment you can trust.

What will happen when I see a physiotherapist?

Bethany’s story

How physiotherapy helped teenager Bethany Sinfield to fight back from a stroke

Your first session with a physio will include a detailed assessment. From this, the physio will create a personal rehabilitation programme for you that meets your needs. With support from the physio you will be encouraged to set your own goals, wherever possible. They may use a range of treatments to aid your recovery.

So that your physio can have a good look at how you move, they may need you to remove some clothes. It’s a good idea to have comfortable clothing and suitable underwear. Everything you tell the physiotherapist will be completely confidential.

Physios are the third largest health profession after doctors and nurses. They work in the NHS, in private practice, for charities and in the work-place, through occupational health schemes.

How can I help myself?

National charity the Stroke Association has information and services for people who have had a stroke, as well as their families and carers.

Top tips for stroke care

  • Your recovery from a stroke will take time – try to be patient with yourself and pace your activities
  • There may be changes in your emotions – don’t be afraid to ask for help to cope with feelings such as sorrow, frustration or anger
  • Keep motivated and practice movements and activities as advised by your physio
  • Ask about what services are available in your area
  • Stroke support groups can provide social contact, as well as help to cope with your condition
  • Stay healthy and enjoy the best quality of life you can.

Guidance and evidence for physiotherapy

  • Physiotherapy Works (Stroke): Clinical evidence for health professionals
  • SIGN (Scotland): Information on NHS treatment

Links and further information

  • NHS Choices: Patient information on stroke
  • Stroke Association: UK charity which funds research and supports patients and families. Helpline: 0303 3033 100

Disclaimer

The content on this page is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation. The CSP is not responsible for the content of any external sites, nor should selection be seen as an endorsement of them.

When someone has a stroke, there’s a need for rapid recognition and action, as emphasised by the FAST (Face, Arm, Speech, Time to call 999) campaign

This hyper-acute stage of the pathway is highly evidence-based, medicalised and thoroughly audited across the UK by the two main stroke audits – Sentinel Stroke National Audit Programme (SNNAP) in England and Wales, and the Scottish Stroke Care Audit (SSCA) in Scotland, with a view to time critical delivery to all eligible patients. However, the subsequent audit around rehabilitation interventions can be less thorough despite a growing body of evidence to support physical interventions.

Ongoing physical rehabilitation: what should we do?

Most patients with stroke will need some kind of ongoing physical rehabilitation to assist them in achieving best outcomesOutcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’. possible (with respect to the severity of the stroke but also with respect to the resource available) and we are increasingly becoming aware that there are some critical elements in achieving that. But can we, and do we, deliver what patients should receive in our publicly funded UK health and social care system and is the evidence sufficiently persuasive to argue strongly for this? How do we ensure that a health condition such as stroke which spans a pathway from the community through hyper-acute medical hospital care, possibly downstream in-patient rehabilitation and back to the community via health and social care is fit for purpose? And how do we remove the diagnostic stroke “badge” and simply allow an individual to function again in society with the support they need to manage their long term condition?

Perhaps there is a persuasive argument for delivering evidence-based stroke rehabilitation with appropriate levels of quality and intensity as it is considered a human right in many societies?

How do we remove the diagnostic stroke “badge” and simply allow an individual to function again in society with the support they need to manage their long term condition?

The evidence for physical rehabilitation after stroke

Evidence for physical interventions relating to walking and physical rehabilitation after stroke is becoming increasingly available in the form of high quality systematic reviewsIn systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. that can inform clinical guidelines as well as high level government strategy with respect to stroke. We tend to find it mostly relating to physical therapy and exercise/fitness interventions.

Updating Cochrane evidence: a novel approach

Pollock et al (2014a) revisited an older Cochrane ReviewCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. (Pollock et al 2009). Previous versions of the review had focussed on physiotherapy interventions for the lower limb and walking after stroke but they decided to use a novel approach in the reappraisal of the literature and update of the evidence. The review was subsequently re-titled Physical Rehabilitation Approaches for the Recovery of Function, Balance and Walking following Stroke. The academic elements of reviewing papers followed the usual Cochrane protocolThe plan or set of steps to be followed in a study. A protocol for a systematic review should describe the rationale for the review, the objectives, and the methods that will be used to locate, select, and critically appraise studies, and to collect and analyse data from the included studies. The protocols for Cochrane Reviews are available in the Cochrane Library..

Seeking “real world” views on the evidence

In order to gauge the relevance of the evidence for clinical practice, but also critically for stroke survivors and carers, in parallel with revisiting the evidence through systematic reviewIn systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research.,co Pollock and colleagues also convened a multi key stakeholder short life working group comprised of stroke survivors, carers and clinical staff. This group was charged with sense-checking and “validating” the evidence as being clinically relevant as it emerged, using formal group consensus methods based on nominal group techniques. This involved a system of voting which focussed the group in reaching consensus. The academic researchers involved in the systematic reviewIn systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. attended the working group meetings and presented the various options in directing the review, but did not vote themselves so as to minimise biasAny factor, recognised or not, that distorts the findings of a study. For example, reporting bias is a type of bias that occurs when researchers, or others (e.g. drug companies) choose not report or publish the results of a study, or do not provide full information about a study.. This arm of the project culminated in a presentation at the 2014 Cochrane UK and Ireland Symposium, held in Manchester, in which key stakeholders in the review led a workshop on user-involvement in writing Cochrane ReviewsCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research.. The dual aims of this work were to determine if physical treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. approaches are effective in the recovery of function and mobility in patients with stroke and to see whether any one physical treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. approach is more effective than any other approach.

The presentation of the updated evidence as a result

Ninety six studies, involving 10,401 stroke were included in the review (Pollock et al 2014a). Results of 27 studies (3243 stroke survivors) could be combined comparing physical rehabilitation with no treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. at all. Twenty five of these studies were carried out in China and were unusual in that they compared an active treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes./intervention group to a control group with no clinical interventionA treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include a drug, surgery, exercise or counselling. . Additional physical rehabilitation versus usual care was described in 12 of these studies demonstrating improved motor function (887 stroke survivors), standing balance (five studies, 246 stroke survivors) and walking speed (14 studies, 1126 stroke survivors). There was also limited evidence of dose intensity for the first time, with treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. durations given between 30 and 60 minutes per day apparently carrying the most significant benefits, but future research needs to verify this.

Key messages:

  • Physiotherapy, using a mix of components from different approaches, is effective for the recovery of function and mobility after stroke. TreatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. sessions of 30-60 minutes, 5-7 days a week may provide a significant beneficial effect.
  • No one approach to physical treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. is any more (or less) effective in promoting recovery of function and mobility after stroke.

Physiotherapists should use their expert clinical reasoning to select individualised, patient-centred, evidence-based physical treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes., with consideration of all available treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. components, and should not limit their practice to a single “named” approach.

Physiotherapy, using a mix of components from different approaches, is effective for the recovery of function and mobility after stroke

Fitness training after stroke

This work is supported by another recently updated Cochrane Review around Fitness Training for Stroke Survivors (Saunders et al 2016) which included 58 trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known. involving 2797 participants with stroke. These studies were grouped according to the type of fitness training interventionA treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include a drug, surgery, exercise or counselling. – cardiorespiratory (28 trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known., 1408 participants) resistance (13 trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known., 432 participants) and mixed training (17 trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known., 4342 participants).

  • Cardiovascular fitness training, particularly involving walking, can improve exercise ability and walking after stroke.
  • Mixed training improves walking ability and improves balance.
  • Unable to draw reliable conclusions regarding effects on quality of life, mood or cognitive function.
  • No evidence of injury or other health problems and exercise appears to be a safe interventionA treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include a drug, surgery, exercise or counselling. .

Circuit Class Therapy

English et al (2017) included 17 trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known. involving 1297 stroke survivors (most of whom could walk 10 metres) in another recent Cochrane Rcoeview to examine the effectivenessThe ability of an intervention (for example a drug, surgery, or exercise) to produce a desired effect, such as reduce symptoms. and safetyRefers to serious adverse effects, such as those that threaten life, require or prolong hospitalization, result in permanent disability, or cause birth defects. of Circuit Class Therapy (CCT) on mobility in adults with stroke. Ten studies (835 participants) measured walking capacity, demonstrating that CCT was superior to the comparison interventionA treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include a drug, surgery, exercise or counselling. , eight measured gait speed again finding that CCT was of significant benefit. Their conclusion was that there was moderate evidence to suggest that CCT is effective in improving mobility for people after stroke. These effects may be greater later after the stroke and stroke survivors may be able to walk further, faster, with more independence and confidence in their balance, but further high quality research is required.

Other relevant reviews

There have also been Cochrane Reviews providing low to moderate quality evidence of the rehabilitation benefits of electro mechanically or robotic assisted gait training devices (Mehrholz et al 2017a), treadmill training for stroke patients who could already walk (Mehrholz et al 2017b) and repetitive task training (French et al 2016). A Cochrane overview (a review of systematic reviews) presenting moderate quality evidence for upper limb rehabilitation after stroke, suggested beneficial effects of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice (Pollock et a. 2014b). Again, information was insufficient to reveal the relative effectivenessThe ability of an intervention (for example a drug, surgery, or exercise) to produce a desired effect, such as reduce symptoms. of different interventions.

So what…

Well, the research evidence, albeit largely of moderate quality, points to the efficacy of a broad range of interventions in the physical rehabilitation of people with stroke, with little detail about which specific interventions are of most value in which settings, and indeed the best delivery mechanisms to make them most easily and effectively implemented. More research is needed to generate higher quality evidence and implementation guidance. Recommendations in stroke guidelines (RCP 2016) and stroke strategies (Scottish Government 2014) have been made on the basis of these findings, particularly with respect to adequate dose. However, given that studies are disparate, have been derived from around the world and as a result conducted within a great variety of different healthcare (and social care/leisure) settings, it is challenging for clinicians to know exactly how to implement the reported findings.

The work of Pollock et al (2014) in engaging multi key stakeholders in making more “real” the findings of their systematic reviewIn systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. made an effort to think about how we might implement the evidence, particularly in relation to the views of stroke survivors, carers and therapists. Perhaps we need to be less defensive of historical professional and service silo boundaries and use this evidence in the best interests of the stroke survivors we aim to serve, though imaginative use of commissioning mechanisms, third sector organisations, the leisure industry, healthcare staff resources and the capacity we have to deliver stroke rehabilitation interventions?

The World Health Organisation (WHO) has recently argued that the benefits of rehabilitation are realised beyond the health sector and that delivered appropriately can reduce care costs and enable participation in education and gainful employment (WHO 2017). With respect to the stroke pathway, if we are serious about saving lives at the “front door”, let’s also make them worth living at the “back door” and beyond.

Join in the conversation on Twitter with @CochraneUK #LifeAfterStroke or leave a comment on the blog.

References may be found here.

Mark Smith is a Trustee of the Stroke AssociationA relationship between two characteristics, such that as one changes, the other changes in a predictable way. For example, statistics demonstrate that there is an association between smoking and lung cancer. In a positive association, one quantity increases as the other one increases (as with smoking and lung cancer). In a negative association, an increase in one quantity corresponds to a decrease in the other. Association does not necessarily mean that one thing causes the other..

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