Motor impairments
1 Progressive resistive exercise
2 Electrical stimulation in conjunction with thera- peutic exercises and activities (e.g., walking) 3 Task-specifi c training – engage in repetitive, pro- gressive exercises and tasks that challenge the patient to acquire motor skills by using the involved limbs during functional tasks and activities
4 Constraint-induced movement should be consid- ered for a selected group of patients with 20 degrees of wrist extension and 10 degrees of fi nger exten- sion, who do not have sensory or cognitive defi cits 5 Body weight-supported treadmill training may be used in selected patients
6 Functional gait task varying surfaces, environ- ments, inclines, steps, speeds, cadence, and dual tasks
7 Lower extremity orthotic devices should be con- sidered if ankle or knee stabilization is needed to help the patient walk
8 Walking assistive devices should be considered to help with mobility, effi ciency, and safety when needed
9 Programs should be structured to be progressive and include challenging exercises and activities
10 Group therapies, self-practice, or robot-assisted devices may provide more opportunity for practice
Spasticity
1 Prevent by positioning, range of motion, stretch- ing, and splinting
2 Consider use of tizanidine or baclofen for spastic- ity that results in pain, poor skin hygiene, or decreased function
3 Use of botulinum toxin, phenol/alcohol neuroly- sis, or intrathecal baclofen should be considered for selected patients with most disabling or painful spasticity
Range of motion and shoulder pain/subluxation 1 Do not use overhead pulleys
2 Bed positioning to prevent shoulder im- pingement
3 Modalities: ice and soft tissue massage
4 Gentle stretching and mobilization, self-range of motion
5 For shoulder range of motion and pain, focus on external rotation and abduction for 90 degrees 6 Educate patient, caregiver, and staff to provide support for a subluxated shoulder during ac- tivities
7 External support for hemiplegic upper extremity during mobility and transfers
8 Reduction of hand edema; active range of motion in conjunction with elevation, or pressure garments
9 Functional electrical stimulation
Sensory training
1 Sensory-specifi c training and cutaneous electrical stimulation may be considered. For hemianopsia, patients should be taught compensatory scanning techniques. Prism glasses may be used to improve visual function in people with homonymous hemi- anopsia, but there is no evidence of a benefi t in ADL function.
ADLs (self-care and mobility)
1 Occupational and physical therapy programs to train and practice self-care activities (i.e., dressing, bathing, feeding)
2 Practice specifi c mobility tasks (rolling, come to sit, transfer, sit to stand, walk)
Cardiovascular fi tness (endurance)
1 Include interventions to increase cardiovascular fi tness once individuals have suffi cient strength in the lower limb muscle groups and have been evalu- ated for exercise tolerance. The exercise evaluation and interventions should follow the recommenda- tions established by the AHA Guidelines on Physical Activity Post-Stroke [43].
Dysphagia
1 Each stroke patient’s swallowing should be assessed
2 Keep all patients NPO (nothing per oral intake) until a healthcare professional trained to administer and interpret a simple, valid, bedside protocol screens patient for swallowing diffi culty
3 Consider enteral feeding for the stroke patient who is unable to maintain adequate oral nutrition
4 Consider feeding tube
5 Swallowing treatment and management by speech and language pathologist when a treatable disorder in swallow anatomy of physiology is identifi ed Bowel and bladder function
1 Incontinence is a major burden and should be managed using an organized functional approach.
Routine use of indwelling catheter is not recom- mended. However, if urinary retention is severe, then intermittent catherization should be used. For individuals with urge incontinence, a prompted voiding regime program and bladder training should be considered.
2 Constipation and fecal impaction are more common after stroke than bowel incontinence.
Goals of management are to ensure adequate intake of fl uid, bulk, and fi ber, and to help the patient establish a regular toileting routine. Stool softeners and judicious use of laxatives may be useful.
Communication
1 Patients with communication disorders should receive early treatment and monitoring of change in communication abilities in order to optimize the recovery of communication skills, to develop useful compensatory strategies when needed, and to facilitate improvements in functional communication.
2 Speech and language pathologists should educate the rehabilitation staff and family/caregivers in techniques to enhance communication with patients who have communication disorders.
3 Interventions may include treatment of phono- logical and semantic defi cits following models derived from cognitive neuropsychology, constraint- induced therapy, and the use of gesture.
4 Patients may be considered for group therapy.
5 Volunteers (including family or staff) trained in supported conversation techniques may be useful.
6 Patients with severe aphasia may benefi t from augmentative and alternative communication devices used in functional activities.
Depression
1 All patients with stroke should be considered to be at high risk for depression. There should be an assessment of patients’ prior history of depression, and they should be screened for depression using a validated tool.
2 Once diagnosed, the treatment of depression and other emotional disorders can improve rehabilita- tion outcomes. If not contraindicated, treatment with psychotherapy and or pharmacotherapy can stabilize mood and improve ability to participate in therapies. Patients should be given the opportunity to participate in support groups and the opportu- nity to talk about their illness and impact of stroke on their lives.
Cognitive defi cits
1 Cognitive defi cits after stroke are common and heterogeneous. All patients should be screened for cognitive impairments using validated screening tools. Screening should establish a patient’s cogni- tive status in domains including arousal, alertness, attention, orientation, memory, language, agnosia, visual–spatial/perceptual function, praxis, and exec- utive function.
2 Patients who demonstrate cognitive impairments should be referred to professionals with specifi c expertise in the areas of cognitive function and intervention strategies. Rehabilitation should be tai- lored to the cognitive impairments identifi ed. Atten- tion training may have a positive effect on targeted outcomes; compensatory strategies may be used to improve memory and apraxia.
Community reintegration
The post-discharge period is consistently reported by patients and their families to be diffi cult. The patients and their families lose social and emotional support. Patients are at high risk for a recurrent stroke, falls, fractures, and functional decline.
Patients and their families should be made aware of community-based outpatient rehabilitation pro- grams, day programs, support groups, and centers for physical and social activity programs. Several studies establish that patients can continue to improve their balance, strength, and endurance with progressive and well-developed exercise programs. In some patients, motor and functional recovery may also continue with highly repetitive training programs, such as constraint-induced movement.
The AHA has developed guidelines for Physical Activity and Exercise for Post-Stroke Survivors [43].
These guidelines provide specifi c recommendations for evaluation of patients for post-stroke aerobic exercise and have made the recommendations for exercise programs. The reader is referred to the fol- lowing site to download the recommendations for preexercise evaluation and the summary of exercise recommendations for stroke survivors (http://circ.
ahajournals.org/cgi/content/full/109/16/2031).
Because stroke patients who return to the com- munity are at an increased risk of falls, they should be assessed for a history of falls and risk for falls on visits to their primary care physician. The falls risk assessment may be guided by the American Geriat- rics Society for Guidelines for Falls Prevention in the Elderly [44]. The Canadian Stroke Best Practice Guidelines recommend for follow-up and commu- nity reintegration after stroke that:
1 Stroke survivors and their caregivers should have their individual psychosocial and support needs reviewed on a regular basis.
2 Any stroke survivor with reduced activity at 6 months or later after stroke should be assessed for appropriate targeted rehabilitation.
3 People living in the community who have diffi - culty with ADLs should have access as appropriate to therapy services to improve or prevent deteriora- tion in ADL.
4 Stroke survivors should continue to be screened and managed for depression.