The primary goals of stroke management are to reduce brain injury, promote maximum recovery following a stroke, and reduce the risk of another stroke. Rapid detection and appropriate emergency medical care are essential for optimizing health outcomes. When available, people with stroke are admitted to an acute stroke unit for treatment. These units specialize in providing medical and surgical care aimed at stabilizing the patient's medical status. Standardized assessments are also performed to aid in the development of an appropriate care plan. Current research suggests that stroke units may be effective in reducing in-hospital fatality rates and the length of hospital stays.

Once a person is medically stable, the focus of their recovery shifts to rehabilitation. Some people are transferred to in-patient rehabilitation programs, while others may be referred to out-patient services or home-based care. In-patient programs are usually facilitated by an interdisciplinary team that may include a physician, nurse, pharmacist, physical therapist, occupational therapist, speech and language pathologist, psychologist, and recreation therapist. Responses to treatment and overall recovery of function are highly dependent on the individual. Current evidence indicates that most significant recovery gains will occur within the first 12 weeks following a stroke. After that, the focus became how to treat patients with stroke.

For most of the last century, people were discouraged from being active after a stroke. Around the 1950s, this attitude changed, and health professionals began prescription of therapeutic exercises for stroke patient with good results. At that point, a good outcome was considered to be achieving a level of independence in which patients are able to transfer from the bed to the wheelchair without assistance.

In the early 1950s, Twitchell began studying the pattern of recovery in stroke patients. He reported on 121 patients whom he had observed. He found that by four weeks, if there is some recovery of hand function, there is a 70% chance of making a full or good recovery. He reported that most recovery happens in the first three months, and only minor recovery occurs after six months.

Constraint-induced movement therapy

The idea for constraint-induced therapy is at least 100 years old. Significant research was carried out by Robert Oden. He was able to simulate a stroke in a monkey's brain, causing hemiplegia. He then bound up the monkey's good arm, and forced the monkey to use his bad arm, and observed what happened. After two weeks of this therapy, the monkeys were able to use their once hemiplegic arms again. This is due to neuroplasticity. He did the same experiment without binding the arms, and waited six months past their injury. The monkeys without the intervention were not able to use the affected arm even six months later. In 1918, this study was published, but it received little attention.

Eventually, researchers began to apply his technique to stroke patients, and it came to be called constraint-induced movement therapy. Notably, the initial studies focused on chronic stroke patients who were more than 12 months past their stroke. This challenged the belief held at that time that no recovery would occur after one year. The therapy entails wearing a soft mitt on the good hand for 90% of the waking hours, forcing use of the affected hand. The patients undergo intense one-on-one therapy for six to eight hours per day for two weeks.

Evidence that supports the use of constraint induced movement therapy has been growing since its introduction as an alternative treatment method for upper limb motor deficits found in stroke populations. CIMT may improve motor impairment and motor function, but the benefits have not been found to convincingly reduce disability, with further research required. Using functional activities as part of the CIMT treatment has been shown to enhance functional outcomes in one's activities of daily living. Occupational therapists are uniquely qualified to provide function-based treatment in conjunction with a CIMT approach. Transcranial magnetic stimulation and brain imaging studies have demonstrated that the brain undergoes plastic changes in function and structure in patients that perform constraint induced movement therapy. These changes accompany the gains in motor function of the paretic upper limb. However, there is no established causal link between observed changes in brain function/structure and the motor gains due to constraint induced movement therapy.

Constraint induced movement therapy has recently been modified to treat aphasia in patients post CVA as well. This treatment intervention is known as Constraint Induced Aphasia Therapy (CIAT). The same general principals apply, however in this case, the client is constricted from using compensatory strategies to communicate such as gestures, writing, drawing, and pointing, and are encouraged to use verbal communication. Therapy is typically carried out in groups and barriers are used so hands, and any compensatory strategies are not seen.

Mental practice/mental imagery

Mental practice of movements, has been shown in many studies to be effective in promoting recovery of both arm and leg function after a stroke. It is often used by physical or occupational therapists in the rehab or homehealth setting, but can also be used as part of a patient's independent home exercise program. Mental Movement Therapy is one product available for assisting patients with guided mental imagery.

Balance

Stroke patients have limited responses to destabilization due to decreased cortical activity . For increasing balance, overall mixed exercises were found to be more effective (i.e., a mix of high-intensity interval training, resistance exercise, and aerobic exercise), while for walking balance, aerobic exercise was found to be more effective

Positioning

The goal of positioning in stroke recovery is for controlling muscle tone, giving proper sensory input, improving body awareness and to prevent joint stiffness, pressure sore, contractures, breathing issues and to make eating safer. there are different types of positioning stroke although there is no one recommended position. According to a survey of physiotherapist the most common positioning used is: 98% use sitting in chair with arm rest, side lying on the affected side then on the unaffected side, 78% sitting in a wheelchair, and lying on the back is less preferred

Virtual Reality

According to the 2025 review by Laver et al., virtual reality, when compared to conventional therapy (weight lifting, task-oriented training, and stretching), leads to slight improvement in upper-limb function and balance, and when combined with usual care, it leads to moderate improvement.

Brain repair

Electrical stimulation

Electrical stimulation is being explored as therapy for stroke rehabilitation with the goal of improving motor function and aid recovery after a stroke. Electrical stimulation therapy involves using electrical currents to stimulate or activate nerves and muscles. This electrical stimulation is meant to mimic the action of healthy muscle to improve function. The goal is to help retrain weak muscles so that they can regain function and perform normal movements. There are numerous approaches and techniques to electrical stimulation therapy including functional electrical stimulation (FES) (electrical current is given to weakened or paralyzed muscles), transcranial direct current stimulation (tDCS): (low electric current is applied to the person's scalp to stimulate specific brain areas), transcutaneous electrical nerve stimulation (TENS), and neuromuscular electrical stimulation (NMES) (muscle stimulation using electrical pulses).

Bobath (NDT)

In patients undergoing rehabilitation with a stroke population or other central nervous system disorders (cerebral palsy, etc.), Bobath, also known as Neurodevelopmental Treatment (NDT), is often the treatment of choice in North America. The Bobath concept is best viewed as a framework for interpretation and problem solving of the individual patient's presentation, along with their potential for improvement. Many studies have been conducted comparing NDT with other treatment techniques such as proprioceptive neuromuscular facilitation (PNF stretching), as well as conventional treatment approaches (utilizing traditional exercises and functional activities), etc.

Mirror Therapy

Mirror therapy (MT) has been employed with some success in treating stroke patients. Clinical studies that have combined mirror therapy with conventional rehabilitation have achieved the most positive outcomes. However, there is no clear consensus as to its effectiveness. In a recent survey of the published research, Rothgangel concluded that

Robotic Rehabilitation

Robot-assisted training enables stroke patients with moderate or severe upper limb impairment to perform repetitive tasks in a highly consistent manner, tailored to their motor abilities. High intensity repetitive task practice delivered via robot-assisted therapy is recommended to improve motor function in individuals in the inpatient, outpatient and chronic care settings.

Stem cells therapies (in research)

Use of bone-marrow derived mesenchymal stem cells (MSCs) in the treatment of ischemic stroke

The terminal differentiation of some somatic stem cells has recently been called into question after studies of transplanted haematopoietic stem cells showed the development of myoblasts, endothelium, epithelium and neuroectodermal cells, suggesting pluripotency. These findings have led to MSCs being considered for treatment of ischemic stroke, specifically in directly enhancing neuroprotection and the neurorestorative processes of neurogenesis, angiogenesis and synaptic plasticity.

Possible mechanisms of neurorestoration and neuroprotection by MSCs after stroke

Transdifferentiation of MSCs into excitable neuron-like cells has been shown to be possible in vitro However, it is unlikely that this degree of transdifferentiation occurs in vivo and that <1% of injected MSCs become truly differentiated and integrate in the damaged area. This suggests that transdifferentiation of MSCs into neurons or neuron-like cells is not a major mechanism by which MSCs cause neurorestoration.

Induction of neurogenesis (development of new neurons) is another possible mechanism of neurorestoration; however its correlation with functional improvement after stroke is not well established. Unlike the induction of neurogenesis, the induction of angiogenesis (development of new blood vessels) by MSCs has been associated with improvements in brain function after ischemic strokes and is linked to improved neuronal recruitment. In addition, synaptogenesis (formation of new synapses between neurons) has been shown to increase after MSC treatment; this combination of improved neurogenesis, angiogenesis and synaptogenesis may lead to a more significant functional improvement in damaged areas as a result of MSC treatment.

MSC treatment also has shown to have various neuroprotective effects, MSC treatment also appears to improve the control of cerebral blood flow and blood–brain barrier permeability, as well as what is currently thought to be the most important mechanism of MSC treatment after stroke, the activation of endogenous neuroprotection and neurorestoration pathways by the release of cytokines and trophic factors.

Although activation of endogenous neuroprotection and neurorestoration probably has a major part in the improvement of brain function after stroke, it is likely that the functional improvements as a result of MSC treatment are due to combined action via multiple cellular and molecular mechanisms to affect neurorestoration and neuroprotection, rather than just a single mechanism. These effects are also modulated by key variables, including the number of and type of MSCs used, timing of treatment relative to when the patient's stroke occurred, route of delivery of the MSCs, as well as patient variables (e.g. age, underlying conditions). it may also be important to address any possible ethical concerns (however unlikely) over the use of somatic stem cells.

Training of muscles affected by the upper motor neuron syndrome

Muscles affected by the upper motor neuron syndrome have many potential features of altered performance including: weakness, decreased motor control, clonus (a series of involuntary rapid muscle contractions), exaggerated deep tendon reflexes, spasticity and decreased endurance.

The term "spasticity" is often erroneously used interchangeably with upper motor neuron syndrome, and it is not unusual to see patients labeled as spastic who demonstrate an array of UMN findings.

It has been estimated that approximately 65% of individuals develop spasticity following stroke, and studies have revealed that approximately 40% of stroke patients may still have spasticity at 12 months post-stroke. The changes in muscle tone probably result from alterations in the balance of inputs from reticulospinal and other descending pathways to the motor and interneuronal circuits of the spinal cord, and the absence of an intact corticospinal system.

While Landau suggests that researchers do not believe that treating spasticity is worthwhile, many scholars and clinicians continue to attempt to manage/treat it.

Another group of researchers concluded that while spasticity may contribute to significant motor and activity impairments post-stroke, the role of spasticity has been overemphasized in stroke rehabilitation.

In a survey done by the National Stroke Association, while 58 percent of survivors in the survey experienced spasticity, only 51 percent of those had received treatment for the condition.

Nonpharmacologic therapies

Treatment should be based on assessment by the relevant health professionals, although there is evidence that caregivers utilise social media communities to source information related to stroke recovery. For muscles with mild-to-moderate impairment, exercise should be the mainstay of management, and is likely to need to be prescribed by a physiotherapist.

Muscles with severe impairment are likely to be more limited in their ability to exercise and may require help to do this. They may require additional interventions, to manage the greater neurological impairment and also the greater secondary complications. These interventions may include serial casting, flexibility exercise such as sustained positioning programs, and patients may require equipment, such as using a standing frame to sustain a standing position. Applying specially made Lycra garments may also be beneficial.

With the prevalence of vision problems increasing with age in stroke patients, the overall effect of interventions for age-related visual problems is currently uncertain. It is also not sure whether people with stroke respond differently from the general population when treating eye problems. Further research in this area is needed as current body of evidence is very low quality.

Physiotherapy

Physiotherapy is beneficial in this area as it helps post-stroke individuals to progress through the stages of motor recovery. These stages were originally described by Twitchell and Brunnstrom, and may be known as the Brunnstrom Approach. Initially, post-stroke individuals have flaccid paralysis. Repetitive task training (RTT), which involves the active practice of task-specific motor activities, improves upper and lower limb function, with improvements being sustained 6-months post-treatment. More research is needed on the type and amount of training.

Unaddressed spasticity will result in the maintenance of abnormal resting limb postures which can lead to contracture formation. to maintain muscle stretch and provide tone inhibition, and cold (i.e. in the form of ice packs), to decrease neural firing, are other strategies that can be used to temporarily decrease the extent of spasticity. The focus of physiotherapy for post-stroke individuals is to improve motor performance, in part, through the manipulation of muscle tone.

Intrathecal drug therapy

Intrathecal administration of drugs involves the implantation of a pump that delivers medication directly to the CNS.

Surgery

Surgical treatment for spasticity includes lengthening or releasing of muscle and tendons, procedures involving bones, and also selective dorsal rhizotomy.

Post-stroke pain syndromes

Chronic pain syndromes are common in about one half of stroke patients. Central post-stroke pain (CPSP) is neuropathic pain which is caused by damage to the neurons in the brain (central nervous system), as the result of a vascular injury. One study found that up to 8% of people who have had a stroke will develop central post-stroke pain, and that the pain will be moderate to severe in 5% of those affected. The condition was formerly called "thalamic pain", because of the high incidence among those with damage to the thalamus or thalamic nuclei. Now known as CPSP, it is characterized by perceived pain from non-painful stimuli, such as temperature and light touch. This altered perception of stimuli, or allodynia, can be difficult to assess due to the fact that the pain can change daily in description and location, and can appear anywhere from months to years after the stroke. CPSP can also lead to a heightened central response to painful sensations, or hyperpathia. Affected persons may describe the pain as cramping, burning, crushing, shooting, pins and needles, and even bloating or urinary urgency. Both the variation and mechanism of pain in CPSP have made it difficult to treat. Several strategies have been employed by physicians, including intravenous lidocaine, opioids/narcotics, anti-depressants, anti-epileptic medications and neurosurgical procedures with varying success. Higher rates of successful pain control in persons with CPSP can be achieved by treating other sequelae of stroke, such as depression and spasticity. As the age of the population increases, the diagnosis and management of CPSP will become increasingly important to improve the quality of life of an increasing number of stroke survivors.

Hemiplegic shoulder pain

Cause

Hemiplegic shoulder pain (shoulder pain on the stroke-affected side of the body) is a common source of pain and dysfunction following stroke. The cause (etiology) of hemiplegic shoulder pain remains unclear. Possible causes may include shoulder subluxation, muscle contractures, spasticity, rotator cuff disorders or impingement, and complex regional pain syndrome. Overall, the shoulder is very mobile, and relies on muscles and ligaments to support it, therefore, if a stroke damages the neurons that control those muscles and ligaments, the joint can be affected and pain may result. For people with spasticity associated shoulder pain, botulinum toxin injections into the shoulder muscles has also been shown to provide significant pain relief and improve range of motion. The use of slings remains controversial. The goal of FES is to strengthen muscle contraction and improve motor control. Different slings are available to manage shoulder subluxation.

Logical treatment consists of preventive measures such as early range of motion, proper positioning, passive support of soft tissue structures and possibly early re-activation of shoulder musculature using functional electrical stimulation. Aggressive exercises such as overhead pulleys should be avoided with this population.

Rehabilitation

Cognitive rehabilitation for spatial neglect following stroke

The current body of evidence is uncertain on the efficacy of cognitive rehabilitation for reducing the disabling effects of neglect and increasing independence remains unproven. However, there is limited evidence that cognitive rehabilitation may have an immediate beneficial effect on tests of neglect. There is limited evidence that training on a driving simulator will improve performance on recognizing road signs after training. Yoga may reduce anxiety and could be included as part of patient-centred stroke rehabilitation. Thus, action observation therapy is generally associated with better arm and hand function, with no significant adverse events. While there may be an immediate effect after treatment on attention, the findings are based on low to moderate quality and small number of studies. MI does not improve motor function after stroke and does not seem to cause significant adverse events. Several forms of apraxia are recognized. Limb-kinetic apraxia is the inability to make precise or exact movements with a finger, an arm or a leg. idiomotor apraxia is the inability to carry out a command from the brain to mimic limb or head movements performed or suggested by others. Conceptual apraxia is similar to idiomotor apraxia, but infers a more profound malfunctioning in which the function of tools or objects is no longer understood. Ideational apraxia is the inability to create a plan for a specific movement. Buccofacial apraxia, or facial-oral apraxia, is the inability to coordinate and carry out facial and lip movements such as whistling, winking, coughing, etc. on command. Constructional apraxia affects the person's ability to draw or copy simple diagrams, or to construct simple figures. Oculomotor apraxia is a condition in which the patient finds it difficult to move his/her eyes. Many believe that the most common form of apraxia is idiomotor apraxia, in which a disconnection between the area of the brain containing plans for a movement and the area of the brain that is responsible for executing that movement occurs.

Unlike many effects of stroke, where the clinician is able to judge the particular area of the brain that a stroke has injured by certain signs or symptoms, the causation of apraxia is less clear. A common theory is that the part of the brain that contains information for previously learned skilled motor activities has been either lost or cannot be accessed. The condition is usually due to an insult to the dominant hemisphere of the brain. More often this is located in the frontal lobe of the left hemisphere of the brain. Treatment of acquired apraxia due to stroke usually consists of physical, occupational, and speech therapy. The Copenhagen Stroke Study, which is a large important study published in 2001, showed that out of 618 stroke patients, manual apraxia was found in 7% and oral apraxia was found in 6%. Both manual and oral apraxia were related to increasing severity of stroke. Oral apraxia was related with an increase in age at the time of the stroke. There was no difference in incidence among gender. It was also found that the finding of apraxia has no negative influence on ability to function after rehabilitation is completed. The National Institute of Neurological Disorders and Stroke (NINDS) is currently sponsoring a clinical trial to gain an understanding of how the brain operates while carrying out and controlling voluntary motor movements in normal subjects. The objective is to determine what goes wrong with these processes in the course of acquired apraxia due to stroke or brain injury. Many different causes can contribute to the acquirement of cognitive impairment after stroke. Among the most common are lesions on specific anatomical structures, such as the hippocampus or entorhinal cortex, white matter lesions, and cerebral microbleeds. The extent and type of cognitive impairment depend on the area of the brain affected by the stroke. However, in general, most cognitive impairment always includes either memory, attention, language, or orientation problems.

There has not been any medication developed yet to treat cognitive deficits resulting from strokes. Although some drugs have shown to be helpful with executive function problems, neither of them has demonstrated significant effects on activities of daily living. Thus, it is important that more work is done on pharmacotherapy and its potential benefits for patients with cognitive decline after stroke. Daily instrumental activities can be understood as those activities that allow an individual to live independently. Even though they are not necessary for living, however, these activities may significantly improve the quality of life. Examples of these activities include cooking, transportation, laundry, and managing finances.

References

Sources

; Lateral medullary syndrome

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; Post-stroke depression

; Neurorehabilitation