Approaches to Stroke Rehabilitation

Rehabilitation of Mobility after Stroke

Stroke survivors may also experience impairments in balance, sensation, strength, muscle tone, endurance, perception, communication, and cognition. Any one or a combination of these impairments may contribute to deficits in bed mobility, moving from one location to another such as from bed to chair, and locomotion on level or unlevel surfaces. Balance impairments are very common following stroke and often are a major limiting factor to ambulation as well as overall function. Biofeedback, visual, proprioceptive and labyrinthine cues, as well as trunk strengthening and stabilization are often used for static and dynamic balance training. Concurrently, transfer training to bed, mat, wheelchair, and commode is initiated. Weight bearing activities often are utilized to facilitate movement and increase sensory input to the affected side. Visualization also may aide in improving performance. Passive range of motion is performed to prevent contractures, and active or active-assisted range of motion helps in strengthening all extremities. Functional electrical stimulation may be used for strengthening the hemiparetic extremities.

Gait training is initiated as soon as possible, and typically requires external manual assistance of therapists, as well as appropriate assistive devices and orthotics. Ankle foot orthoses (AFO) stabilize the ankle and assist with toe clearance. An AFO with an ankle joint also may be used to facilitate knee flexion or extension when knee control is unstable during the gait cycle. Knee-ankle-foot-orthoses (KAFO) are used less frequently to completely stabilize severely weak knee and ankle joints.

Early and intensive gait training is very safe and effective for the recovery of ambulation. Use of treadmills with partial body weight support improves motor recovery, functional balance, gait symmetry, and over ground walking speed and endurance, while decreasing abnormal tone. Ambulation training should be progressed from level, controlled hospital environments to uneven surfaces, stairs, and community environments as timing, control and balance improve. External supports, orthoses, and devices should be minimized as gait becomes more independent. Risk factors for falls, such as a history of stroke, advanced age, and balance impairments, should be addressed to determine whether the stroke survivor has a good prognosis for independent ambulation.

Stroke survivors who have limited or no ability to ambulate may require a wheelchair as a primary means of mobility. They should be evaluated and fitted for a wheelchair by a team consisting of a therapist, physician, equipment vendor, the patient, and his/her caregiver. The typical "hemi" chair requires a low (drop) seat for propulsion with the uninvolved upper and lower extremities. Removable arm and leg rests facilitate the ability to transfer to and from the wheelchair. A half lap tray sometimes is required for positioning of the involved upper extremity. A seat belt and anti tippers may be recommended if the stroke survivor is at risk for falling. Lightweight wheelchairs are appropriate for patients with decreased endurance. A seating system may be required to maximal midline support and positioning of the trunk, and symmetrical weight bearing through the pelvis. A pressure-relief cushion decreases the risk for skin breakdown.

Stroke survivors who are not independent with transfers, locomotion or ADL's will require caregiver training. Caregivers are taught safe techniques to assist the stroke survivor with transfers, locomotion, range of motion exercises, and positioning to avoid pressure sores. They also may need to learn management of medications, nutrition, and bowel and bladder function.