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Optimizing Stroke Recovery: Timing, Intensity, and Duration of Rehabilitation
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How Early Should Therapy Start After A Stroke?
Individuals that are considered medically stable following a stroke yet are still hospitalized will likely have physician’s orders to be evaluated by the rehabilitation team while in acute care. Physical therapy, occupational therapy, and speech therapy often provide an early assessment to identify impairments, functional status, levels of independence, support needs, and potential safety issues. The rehabilitation team and physician providers will explore options for continued rehabilitation. As appropriate, recommendations may include inpatient rehabilitation (e.g. hospital-based rehabilitation, often lasting 2-4 weeks), skilled nursing facility, long-term rehabilitation center, home therapy, or outpatient therapy (e.g. able to transport to a facility outside of the hospital while living at a home residence).
How Intensive Should Therapy Be After A Stroke?
Evidence is mounting that intensive rehabilitation (i.e. the individual is pushed to levels of high exertion) is not recommended in the early hours (24 hours) or days following stroke. Many publications and expert opinions state that it may be harmful to the nervous system that is rapidly undergoing a state of repair following ischemic or hemorrhagic damage. (1)
“The latest guidelines for management of acute ischemic stroke from the American Stroke Association indicate that high-dose mobilization within 24 hours of stroke onset should not be performed because it can reduce the odds of a favorable outcome at 3 months.” (2)
Intensive rehabilitation can be provided when the team has factored in several considerations, including medical stability and individual tolerance. Oftentimes, a progressive approach is used in which there is a slow build-up of challenge (e.g. how long the individual works, how hard the individual works, how many days a week the individual works, and what types of activities/exercises are provided). Rehabilitation should always be tailored to the individual’s needs at all points within the therapy timeline.
In conclusion, following the early days after a stroke, intensive rehabilitation after a stroke is often recommended and has been shown to have positive effects on recovery outcomes aimed at maximizing functional gains and promoting neuroplasticity.
1. Coleman ER, Moudgal R, Lang K, Hyacinth HI, Awosika OO, Kissela BM, Feng W. Early Rehabilitation After Stroke: a Narrative Review. Curr Atheroscler Rep. 2017 Nov 7;19(12):59. doi 10.1007/s11883-017-0686-6. PMID: 29116473; PMCID: PMC5802378.
2. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al.. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke (2018) 49:e46–110. 10.1161/STR.0000000000000158
How Long Should Therapy Continue After A Stroke?
No matter how severe the lasting symptoms are after a stroke, many individuals continue to find skilled therapy beneficial. This may mean the individual goes to therapy for short and occasional “tune-ups” for new exercises and activities, or it could mean the individual stays enrolled in consistent therapy one or more days per week as long as there are observable benefits and value.
Stroke rehabilitation is often a long-term process that can continue for months or even years after a stroke.
Are There Any Specific Exercises Or Therapies For Stroke Recovery?
Customizing exercises and therapeutic activities for individuals is necessary to ensure that they are appropriate, safe, and will ultimately provide benefit.
There are a broad range of impairments that are associated with stroke. There are also a wide range of exercises and therapies that provide rehabilitation in these areas. The following list serves a general overview of therapies available for different types of symptoms/impairments.
To ensure you are doing the right exercises and making the most of your effort and time, consult with a rehabilitation specialist who can address your specific needs. However, stroke recovery resources with exercises are available for free. For example, you can download the free exercise playbook by Neurolutions for at-home exercises.
Exercises for Improved Movement after Stroke:
- Stretching and range of motion (ROM) exercises
- Optimal positioning of arm/hand (in case of support for the very weak arm, subluxation of shoulder, contracture management, and enhancing limb awareness)
- Resistance training
- Constraint-Induced or Modified Constraint-Induced Movement Therapy (CIMT, mCIMT)
- Electrical stimulation
- Sensory reeducation with sensorimotor training to improve tactile (sensation) feedback motor planning sensory and proprioceptive (knowledge of limb position) awareness
- Mirror therapy
- Mental practice/mental imagery
- Action observation training
For detailed information, visit these resources:
Exercises for Vision Disturbances after Stroke
There are many types of vision disturbances that can occur after stroke. A comprehensive evaluation of the eyes as well as visual perception is required by an expert in neuro optometry, neuro ophthalmology, and neurorehabilitation (i.e. occupational therapists, vision therapists). It is critical to address the root cause of the impairment before starting any formal plan. Exercises and therapies may include a combination of restorative and compensatory techniques.
Visit Vision Disturbances and Management Post-Stroke for more information.
Exercises to Address Fatigue and Reduced Aerobic Capacity
Rehabilitation interventions for fatigue, reduced stamina, and aerobic capacity post-stroke typically focus on improving overall cardiovascular fitness and endurance.
Here are some common interventions that are used:
- Aerobic exercise
- Task-specific training
- Circuit training
- Respiratory muscle training
- Education and lifestyle modification
Exercises to Improve Cognitive Functions after Stroke
Cognitive rehabilitation exercises and interventions in post-stroke rehabilitation aim to improve cognitive functions. Here is a list of some common approaches and exercises used in cognitive rehabilitation:
- Memory training
- Attention and concentration training
- Problem-solving and reasoning exercises
- Cognitive stimulation exercises
- Executive functioning training
- Compensation training
- Group skills and support
It is important to note that all exercises and therapy should be tailored to each individual’s specific strengths and weaknesses. For a more expansive understanding of each of these topics, check out our stroke information and recovery blog.
What Can I Do If My Progress Has Stalled or Plateaued?
- Remember that recovery is often a marathon and not a sprint. A little progress every day can lead to big achievements. Keep fighting the good fight with daily discipline.
- Those in the chronic phase post-stroke have more recovery options now than ever before. Additionally, emerging research shows that the brain can make positive changes toward functional improvement under the right conditions that promote neuroplasticity. For more information, refer to our Complete Guide to Chronic Strokes.
- Continue with rehabilitation you consider challenging and intensive, if possible.
- Brain recovery is not a passive process. It relies on your persistence in rehabilitation, your support system, and expanding your resources to get to where you want to go.
- Keep progressing with the exercises/activities that have become too easy for you. It is also good to switch up your routine to challenge your brain and body with new activities.
- Discontinue activities that appear to be a waste of time, effort, and money. Talk to your trusted support system and healthcare professionals to gauge this if you are unsure.
- Be aware of activities that could be contributing to lack of progress. This could be an intervention/technology that is not giving value nor benefit. It could be due to self-selecting activities or a lifestyle that does not promote recovery efforts (e.g. excessive TV watching, substance abuse, relying on others for everything).
- You may have to do therapy from home on your own without regular rehabilitation. It is still possible to be successful through home rehabilitation. Have your therapist design a challenging yet safe plan for you that incorporates a method to record your progress so you can stay motivated and be accountable for hitting certain milestones.
- Measure progress and journal often to determine if new approaches or routines are working.
- Be open to trying new technologies as long as you have received education on the purpose and the goal of the technology.
- Consistency and regular practice are key in stroke rehabilitation. Make sure you are following your rehabilitation program, adhering to any exercises, therapies, or strategies recommended by your healthcare team. Engage in regular practice sessions at home or with the guidance of a therapist to reinforce and build on your progress. Progress is not just about what you do in rehabilitation, it is also what you do when you’re not under the watchful eye of a therapist.
- It is important to consider that you may be making excellent progress, but you don’t see it. Sometimes day-to-day changes are too small to detect. There is also a tendency to make judgements based on expectations of where you were in your prime. While that is understandable, the gap between where you are now and where you want to be may feel miles away.
Can the Brain Heal Itself After a Stroke?
Neuroplasticity is a fundamental mechanism through which the brain can adapt and reorganize itself after a stroke or any other form of brain injury. Neuroplasticity allows the brain to form new connections between neurons, reassign functions to undamaged areas, and promote recovery of lost abilities.
Intensive exercise therapy, such as physical and occupational therapy, is indeed a key component in stimulating neuroplasticity and promoting recovery after a stroke. By engaging in specific exercises and repetitive movements, individuals can enhance neural pathways associated with motor skills, coordination, and mobility. This targeted therapy encourages the brain to rewire itself, strengthen existing connections, and develop new ones to compensate for damaged areas.
Additionally, certain technologies designed to strengthen connections and encourage new pathways to uninjured parts of the brain are now commercialized. For more information, check out the IpsiHand.
The brain’s ability to heal and recover after a stroke is influenced by various factors, including the location and severity of the stroke, the individual’s overall health and age, and their commitment to rehabilitation. Recovery is often a gradual and ongoing process that can continue for months or even years after a stroke. However, with proper rehabilitation and the brain’s inherent neuroplasticity, significant improvements in motor skills, including walking, can be achieved.
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