In all but the most seriously ill patients, beginning within a few days of the stroke the paralyzed limbs ideally should be carried through a full range of passive movement several times a day. The purpose is to avoid contracture (and capsulitis), especially at the shoulder, elbow, hip, and ankle. Soreness and aching in the paralyzed limbs should not be allowed to interfere with exercises to the extent possible. Patients should be moved from bed to chair as soon as the stroke is completed and blood pressure is stable. Prophylaxis for deep venous thrombosis with compression boots or anticoagulation is appropriate if the patient cannot be mobilized. An assessment for swallowing difficulty should be made early during recovery and dietary adjustments on the insertion of a nasogastric tube made if there is a risk of aspiration. Nearly all hemiplegic patients regain the ability to walk to some extent, usually within a 3to 6-month period, and this should be a primary aim in rehabilitation. The presence of deep sensory loss or anosognosia in addition to hemiplegia, are the main limiting factors. A short or long leg brace is often required. By teaching patients with cerebellar ataxia new strategies, balance and gait disorders can be made less disabling. As motor function improves and if mentality is preserved, instruction in the activities of daily living and the use of various special devices can help the patient become at least partly independent at home. Whatever little research is available on the effectiveness of stroke rehabilitation suggests that a greater intensity of physical therapy does indeed achieve better scores on some measures of walking ability and dexterity. In a randomized trial, Kwakkel and colleagues achieved these results by applying an additional 30 min/d beyond conventional physical therapy of focused treatments to the leg or arm, 5 d/week, for 20 weeks. Other studies have demonstrated clearly the undesirable effects of immobilizing a limb in a splint after a stroke.
Experimental work in monkeys and limited data from patients suggest that improvement can be obtained by restraining the normal limb and forcing use of the sound limb. In a randomized trial, Wolf and colleagues (2006) were able to demonstrate a benefit from this form of “constraint therapy” by forcing the patient to wear a mitt on the good hand while engaging in persistent exercises with the hemiplegic limb for more than 90 percent of their waking time through 2 weeks. This may reflect functional expansion of the cortical motor representation into adjacent undamaged cortical areas, indicating the potential for some degree of reorganization that corresponds to clinical recovery. A related approach, “mirror therapy” confronts the patient with a mirror that creates an illusion of moving the paretic side when the good side is activated. The Cochrane meta-analysis of 14 such studies indicates a modest benefit in motor recovery and a more prominent benefit for relief of pain and quality of life improvement (Thieme and colleagues).
The neural substrates of improvement after stroke are just beginning to be studied. Considerable clinical experience and physiologic data such as those reported by Luft and colleagues have demonstrated that the injured brain has some degree of plasticity; remodeling of brain tissue and reorganization of neural function may occur with training even months after large strokes.
Speech and language therapy is particularly valuable in identifying the risk of aspiration as noted above. Specific therapy should be given in appropriate cases and certainly improves the morale of the patient and family. Further comments on such treatments can be found in Chap. 22.
GENERALIZED BRAIN ISCHEMIA AND HYPOXIA (SEE ALSO CHAP. 39)