ANALYSIS & PERSPECTIVE
A Unified Model for Stroke Recovery and Rehabilitation
Why Now?
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
Preeti Raghavan, MD
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/03/2023
Abstract: The current model of stroke care delivery in the United
States and in many parts of the world is fragmented, resulting in lack
of continuity of care, inability to track recovery meaningfully across
the continuum, and lack of access to the frequency, intensity, and dura-
tion of high-quality rehabilitation necessary to optimally harness recov-
ery processes. The process of recovery itself has been overshadowed by
a focus on length of stay and the movement of patients across levels of
care. Here, we describe the rationale behind the recent efforts at the
Johns Hopkins Sheikh Khalifa Stroke Institute to define and coordinate
an intensive, strategic effort to develop effective stroke systems of care
across the continuum through the development of a unified Sheikh
Khalifa Stroke Institute model of recovery and rehabilitation.
Key Words: Stroke, Rehabilitation, Therapy, Disability, Value, Cost
(Am J Phys Med Rehabil 2023;102:S3–S9)
here are more than 80 million stroke survivors worldwide1;
T this staggering number is only matched by the equally
enormous stroke-related medical costs that are projected to ex-
ceed US $183 billion annually by 2030.2 Although the overall
burden of stroke, as quantified by age-standardized disability-
adjusted life years, has decreased in the last three decades, the
absolute number of disability-adjusted life years due to stroke
has increased because of population growth and aging result-
ing in a higher prevalence of chronic stroke.1 The trends are
similar in the Middle East and North Africa.3 In most regions
metabolic risks (high systolic blood pressure, high body-mass
index, high fasting plasma glucose, high total cholesterol, and
low glomerular filtration rate), and behavioral factors (smoking,
poor diet, and low physical activity) account for the largest pro-
portion of stroke disability-adjusted life years. Rehabilitation is
necessary both for reducing the burden of disability and for
modification of risk factors to reduce the enormous societal
and economic burden of stroke.
Rehabilitation services after stroke in the United States are
highly heterogeneous and vary by the type of care setting (acute
hospital service, acute inpatient rehabilitation, subacute facility,
home care services, or outpatient rehabilitation), duration of re-
habilitation (length of stay in the specific setting), frequency of
From the Department of Physical Medicine and Rehabilitation and Neurology, Johns
Hopkins University School of Medicine, Baltimore, Maryland.
All correspondence should be addressed to: Preeti Raghavan, MD, 600 N Wolfe St,
Phipps Building, Suite 174, Baltimore, MD 21287.
This work is funded by the Johns Hopkins Sheikh Khalifa Stroke Institute.
Financial disclosure statements have been obtained, and no conflicts of interest have
been reported by the authors or by any individuals in control of the content of
this article.
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115
DOI: 10.1097/PHM.0000000000002141
American Journal of Physical Medicine & Rehabilitation • Volume 102, Number 2 (Suppl), February 2023
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
therapy sessions per week, intensity of the therapy sessions, and
type of interventions delivered.4 The American Heart Associa-
tion’s guidelines recommend consultation by a rehabilitation spe-
cialist leading a multidisciplinary team as soon as possible, ideally
within 24 hours, for a patient admitted with a diagnosis of stroke.5
Unfortunately, the focus of this consultation is typically on transi-
tion of care and selection of the discharge destination,6–8 rather
than on providing multidisciplinary rehabilitation interventions
focused on facilitating recovery to reduce long-term disability.
This is particularly problematic because mortality at 1 yr after
stroke is strongly predicted by ambulatory status at discharge
from the acute hospital stroke service—patients who needed as-
sistance to walk and were nonambulatory at discharge were
more likely to die at 1 yr than those who were ambulatory at dis-
charge.9 Hence, enhancing mobility should be a priority in the
days immediately after stroke.
It is well known that poststroke immobility can lead to in-
creased risk of falls, fractures, pneumonia, pressure ulcers, and
pulmonary embolism and increases healthcare costs substan-
tially, whereas early, high-frequency rehabilitation can reduce
these complications and reduce healthcare costs.10–13 In addi-
tion, immobility limits cardiovascular exercise and increases
the risk for recurrent stroke or cardiovascular illness, and recent
guidelines emphasize the importance of facilitating physical
activity poststroke, which in turn has been shown to reduce re-
admissions, mortality, and healthcare costs.14–18 Thus, it is
now imperative to implement early recovery-focused rehabili-
tation in the real world to best serve our patients, mitigate dis-
ability, and reduce unnecessary long-term healthcare costs.19
Hence, we—the leaders, faculty, and staff at the Johns Hopkins
Sheikh Khalifa Stroke Institute (SKSI)—collaborated to de-
velop the unified SKSI model of recovery and rehabilitation,
which we describe here.
RECOVERY AFTER STROKE: WHAT IS NEEDED?
Recovery after stroke occurs across all domains (e.g., mo-
tor, sensory, cognition, perception, language). One of the most
studied areas of recovery is in the motor domain. Motor recov-
ery is defined in terms of recovery of motor performance rather
than recovery of neural integrity, because any kind of recovery
of performance after neural injury will require both neural repair
and neural compensation.20 Recovery of motor performance or
skill is defined as the reappearance of elemental motor patterns
present before central nervous system injury.21 In contrast, mo-
tor compensation is defined as the appearance of new motor
patterns resulting from the adaptation of remaining motor ele-
ments or substitution, meaning that functions are taken over,
replaced, or substituted by different body segments. Reha-
bilitation providers must carefully balance the need to restore
function by teaching compensatory strategies versus striving
www.ajpmr.com S3
 Raghavan
for improvements in movement quality by reducing motor im-
pairment. The degree of poststroke motor impairment has been
shown to be a key factor in the extent of recovery that is possi-
ble.22,23 However, biologic processes of neural repair interact
with behavioral activity to influence recovery (Fig. 1),24 and
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
these processes are similar to those that occur in skill learning
in individuals without neurologic injury.
A vast amount of evidence accumulated in the last three
decades has shown that recovery after stroke is dependent on
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/03/2023
the timing, frequency, intensity, and content of rehabilitation
interventions delivered after stroke.25 For example, high-intensity
and long-dose therapy when given progressively, consistently,
and repetitively following motor learning principles substan-
tially reduces motor impairment and increases function even in
patients with moderate-to-severe motor impairment in the chronic
stage poststroke.26–29 In an upper limb study of long-dose ther-
apy, Daly et al. asked whether individuals with moderate/
severe impairment in the chronic phase after stroke respond
to high-dose therapy (300 hrs) or experience a midtreatment
plateau and whether gains in motor impairment and function
were retained after treatment. Pretreatment to midtreatment
and midtreatment to posttreatment gains in motor impairment,
measured using the Fugl-Meyer scale, were statistically and
clinically significant, indicating no plateau at 150 hrs and a
continued benefit from the second half of treatment. From base-
line to 3-mo follow-up, the gains in motor impairment were
twice the clinically significant benchmark, and gains in func-
tion, measured using the Arm Motor Ability Test, were greater
than the clinically significant benchmark. From posttreatment
to 3-mo follow-up, gains in motor impairment were maintained,
FIGURE 1. Biologic principles of neural repair can inform rehabilitation therapeutics. From Carmichael24 (2016), with permission.
S4 www.ajpmr.com
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Volume 102, Number 2 (Suppl), February 2023
and there were statistically significant gains in function.26 The
Queen Square Upper Limb Neurorehabilitation program provided
high-dose, high-intensity upper limb neurorehabilitation for
5 days a week over 3 wks (90 hrs total) for patients with
chronic stroke and reported significant changes in arm motor
impairment, measured using the modified Fugl-Meyer Scale,
and arm function, measured using the Action Research Arm
Test and the Chedoke Arm and Hand Activity Inventory 13.
There were clinically and statistically significant gains at the
end of the 3-wk intervention that persisted for 6 mos after the
program ended.27 In a separate study, hand dexterity and finger
independence also increased in patients with chronic stroke that
received high-intensity training, and the reduction in impair-
ment was maintained for 6 mos after training.28 The mecha-
nisms of improvement in dexterity in patients with chronic
stroke have been shown to involve sensorimotor integration
and changes in muscle coordination, which may be noted af-
ter a single session of training with the appropriate type of
practice.30 Similarly, in a lower limb study, an array of interven-
tions targeted treatment-resistant impairments underlying persis-
tent mobility dysfunction, such as weakness, balance deficit, limb
movement dyscoordination, and gait dyscoordination over 6
mos, and showed clinically or statistically significant improve-
ments in an array of measures of impairment, functional mo-
bility, and personal milestone achievements.29 These studies
suggest that even chronic stroke patients can benefit from
high-intensity, high-dose therapy, with persistent reduction
in disability.
More recently, the value of an additional 20 hrs of therapy
given early on (within 3 mos) during a presumed critical period
© 2023 Wolters Kluwer Health, Inc. All rights reserved.
 Volume 102, Number 2 (Suppl), February 2023
after stroke was tested. The study showed that patients who re-
ceived the additional therapy in the acute (within 1 mo) and
subacute (between 2 and 3 mos) period poststroke had signifi-
cantly reduced arm motor disability measured using the Action
Research Arm Test at 1 yr compared with those who received
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
the same amount of therapy in the chronic stage (after 6 mos)
or did not receive additional therapy.31 Taken together, these
studies suggest that impairment-focused therapy can improve
the extent of recovery at any stage, but the dose of therapy re-
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/03/2023
quired may be far greater in the chronic stage relative to the
acute and subacute stages. Furthermore, retraining cardiovas-
cular capacity within 3 mos poststroke may also have a non-
specific effect on mobility, activities of daily living, and cog-
nition as measured by patient-reported outcomes.15,17 Thus,
optimizing high-dose skill training as well as cardiovascular
capacity during the period of biologic recovery may be particu-
larly conducive to motor recovery after stroke (Fig. 2) and im-
portant to mitigate long-term disability and the associated
healthcare costs. A key question is—how can we consistently
deliver high-dose stroke rehabilitation in the real world?
A UNIFIED MODEL OF STROKE CARE
Postacute stroke care is delivered in silos created by mul-
tiple healthcare settings and specialties, making it difficult to
translate the available scientific evidence into optimal care de-
livery. The mission of the SKSI is to “transform the care of pa-
tients with stroke to facilitate optimal recovery and ultimately
prevent or reduce disability.” To deliver on this core mission,
we needed to define and coordinate an intensive, strategic ef-
fort to treat stroke, and promote recovery to the greatest ex-
tent possible, and as early as possible to mitigate long-term
disability. Furthermore, the early poststroke period is the op-
timal time to instill a positive attitude and develop life habits
that are necessary for both recovery and secondary preven-
tion. Physical ability, neuropsychological, and life habit
FIGURE 2. Poststroke recovery occurs at the intersection of biologic repair processes, skill retraining through task-specific therapies, and rebuilding
cardiovascular capacity.
© 2023 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Unified Model for Stroke Recovery
characteristics in turn predict the recovery time for indepen-
dence in poststroke abilities and need to be optimized early
poststroke to reduce the socioeconomic impact caused by
poststroke disability.32,33
A critical first step in delivering on our mission was to
bridge the continuum of care for patients with stroke to create
a unified transdisciplinary focus on the patient’s recovery and
rehabilitation. Specifically, we needed to integrate care deliv-
ery across the system (i.e., the acute hospital stroke service,
the acute inpatient rehabilitation service, and the outpatient
stroke service), and build an outcomes database to be able to
consistently and reliably tailor clinical care and measure the
changes in outcomes across the continuum. The outcome mea-
surements also enable the development of algorithms to match
the timing, dose, and content of therapy/rehabilitation sessions
to each patient more precisely, given their level of impairment
and cardiovascular capacity. Our next step will be to test the ef-
fectiveness of the model and disseminate our learnings both
within Johns Hopkins and in the United Arab Emirates, as well
as nationally and internationally (Fig. 3).
FACTORS TO CONSIDER IN
RECOVERY-CENTERED DELIVERY OF
REHABILITATION SERVICES
Stroke recovery is complex. The delivery of rehabilitation
is impacted by impairments across multiple domains, such
as motor planning, weakness, spasticity, sensory perception,
sensory-motor integration, motor cognition, and language, etc.,
which in turn impact function and participation as per the World
Health Organization’s International Classification of Function-
ing, Disability, and Health model.34 There is a many-to-one re-
lationship between impairment and function, and function and
participation, which makes impairment-focused treatment dif-
ficult to deliver. For example, difficulty performing a func-
tional activity such as drinking from a cup may be caused by more
www.ajpmr.com S5
 Raghavan Volume 102, Number 2 (Suppl), February 2023
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/03/2023

FIGURE 3. The unified SKSI model for recovery and rehabilitation.

than one impairment, including muscle weakness, spasticity,
tactile and proprioceptive sensory loss, as well as apraxia and
perhaps executive dysfunction. An inability to drink from a
cup is just one function that affects participation in one’s
self-care. Each impairment needs to be addressed to increase
function, and multiple functions must be addressed to increase
participation. Similarly, it is also possible that reducing only
one impairment might make no difference to a person’s func-
tion. Thus, it is not surprising that patients with several and
more severe impairments need longer and higher-dose inter-
ventions and that change in function and participation may be
slower; nevertheless, they do occur.26–29 Second, patients with
severe stroke may get physically deconditioned quickly,
compromising their cardiovascular capacity to participate in daily
life activities. These patients need early rehabilitation to pre-
vent the adverse consequences of immobility and decondition-
ing that can further compromise their recovery. However, in
our present system of care, more severely impaired patients
get even less rehabilitation than their less-severely impaired
counterparts as shown by the inverted pyramid (Fig. 4). This
further exacerbates their disability and escalates healthcare
costs because of the complications of immobility and increas-
ing dependence on others. Globally, 73% of stroke survivors
fall within 6 mos and are 4 times more likely to fracture their

FIGURE 4. The current inverted pyramid model of rehabilitation provides lower frequency and intensity of rehabilitation to the most impaired, which
can exacerbate disability and escalate healthcare costs. The desired upright pyramid model of care would deliver more frequent rehabilitation at the
highest tolerated intensity to prevent the downstream effects of immobility and deconditioning on recovery processes.

S6 www.ajpmr.com © 2023 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

 Volume 102, Number 2 (Suppl), February 2023 Unified Model for Stroke Recovery
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/03/2023

FIGURE 5. The three dimensions of severity of impairment, acuity of stroke, and personal factors influence the rate of recovery and should be
considered in determining the frequency, intensity, duration, and content of rehabilitation interventions to optimize recovery.

hip.35 Furthermore, stroke survivors are sedentary 78% of the
time because of slow walking speed and are likely to be more
dependent.36,37 A more desired, upright pyramid model would
deliver more frequent rehabilitation at the highest tolerated in-
tensity to severely impaired patients to prevent the effects of
immobility and deconditioning on recovery processes. Perform-
ing frequent bouts of physical activity, for instance, has been
shown to improve cardiovascular risk poststroke.38
Personal and environmental factors, such as one’s prestroke
identity, level of motivation, attitude, self-efficacy, and access
to resources and support, also affect daily behaviors that impact
recovery from impairment, as well as function and participa-
tion.39 A recent systematic review of peer-reviewed, qualitative
studies on the perceived factors influencing physical activity
levels of independently mobile community-dwelling adults
greater than 3 mos after stroke, showed that physical activity
levels in stroke survivors are influenced by social activities
and support, prestroke identity, self-efficacy levels, and com-
pletion of activities that are meaningful to stroke survivors.40
High-impact interventions are those that have an effect on all
three International Classification of Functioning, Disability,
and Health domains of impairment, function, and participation,
by simultaneously reducing several impairments at once. Such
interventions typically harness natural repair mechanisms (that
are active during the critical period)24 and/or upregulate these
mechanisms, such as by combining aerobic exercise,41 or
in enriched environments, for example, by incorporating music
therapy.42 Hence, delivering interventions during the acute period

TABLE 1. Differences between the current standard of care and the SKSI model of care

Current Standard of Care SKSI Model of Care

Acute hospital stroke service
• Rehabilitation consultation to determine discharge
destination
• 1–3 therapy sessions for the duration of the length of stay
in the stroke unit
• Stroke binder consisting of educational resources provided
by the American Heart Association
Acute inpatient rehabilitation service
• Function-focused regardless of impairment
• 3 hrs of therapy per day
• One family meeting per admission
Outpatient stroke service
• Typical frequency 2–3 d/wk for PT, OT, ST, and
neuropsychology if needed
• Struggle to discharge patients and to keep patients
• Lack of continuity of care
OT, occupational therapy; PATH, postacute therapy; PT, physical therapy; SLP, speech and language pathology.
• Assess impairments, function, participation using a standard SKSI battery
• Medically cleared patients receive two 15- to 30-min sessions of PT, OT, and SLP each
daily; one focused on impairment reduction and the other on enhancing function
• Patients are involved in social activity to encourage self-management and promote
self-efficacy
• Assess impairments, function, and participation using a standard SKSI battery
• Optimize training time within length of stay beyond three hours of therapy per day
• Focus on impairment reduction
• Engage and empower patients and caregivers to participate to enhance self-efficacy
• Implement a discharge algorithm to bridge the care to outpatient services
• Assess impairments, function, and participation using a standard SKSI battery
• Select from multiple PATH transdisciplinary programs depending on acuity, severity, and
personal factors
• High-frequency PATH (4–5 d/wk)
• Intermediate-frequency PATH (2–3 d/wk)
• Low-frequency PATH (1 d/wk)
• Focus on impairment reduction
• Engage and empower patients and caregivers to participate to enhance self-efficacy

© 2023 Wolters Kluwer Health, Inc. All rights reserved. www.ajpmr.com S7

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

 Raghavan
or in conjunction with aerobic exercise,43,44 could be particularly
beneficial. Figure 5 shows the three dimensions that greatly influ-
ence the rate of recovery–acuity of stroke, severity of impairment,
and personal factors–which should be considered in determining
the frequency, intensity, and content of rehabilitation interventions
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
to optimize recovery.
DIFFERENCES BETWEEN THE STANDARD OF
CARE AND THE UNIFIED MODEL OF CARE
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/03/2023
The unified model of care for recovery and rehabilitation
at the SKSI seeks to optimize recovery by innovatively en-
hancing the standard of care as shown in Table 1. This oc-
curs through enhanced communication across the acute care,
inpatient rehabilitation, and outpatient rehabilitation settings,
and the multidisciplinary team, which includes physicians
in the departments of physical medicine and rehabilitation
and neurology, therapists in physical, occupational and speech
therapy, psychologists, nurses, researchers, and staff. Our goal
is to develop a stroke recovery program that combines innova-
tive clinical care, technology, and research for predictive (iden-
tifying the right frequency, intensity, and content based on the
factors that influence recovery), preventive (providing early
rehabilitation to prevent the complications of immobility),
personalized (considering the personal factors that influence
recovery), and participatory (engaging patients throughout
the continuum) rehabilitation.
CONCLUSIONS
Implementation of the SKSI model requires that we learn
from and teach one another. It has led to the development of
better standards of practice to ensure more effective stroke
systems of care across the continuum informed by the latest
scientific research and discovery. The articles in this sup-
plement represent a synthesis of our collective effort and
an attempt to share our learnings toward a recovery-focused
learning network.
ACKNOWLEDGMENTS
The author thanks Dr Pablo Celnik, Dr Justin McArthur,
and faculty and staff from the departments of physical medi-
cine and rehabilitation and neurology involved in the Sheikh
Khalifa Stroke Institute.
REFERENCES
1. GBD 2016 Stroke Collaborators: Global, regional, and national burden of stroke, 1990–2016:
a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2019;18:
439–58
2. Ovbiagele B, Goldstein LB, Higashida RT, et al: Forecasting the future of stroke in the United
States: a policy statement from the American Heart Association and American Stroke
Association. Stroke 2013;44:2361–75
3. Jaberinezhad M, Farhoudi M, Nejadghaderi SA, et al: The burden of stroke and its attributable
risk factors in the Middle East and North Africa region, 1990–2019. Sci Rep 2022;12:2700
4. Raghavan P: Research in the acute rehabilitation setting: a bridge too far?
Curr Neurol Neurosci Rep 2019;19:4
5. Winstein CJ, Stein J, Arena R, et al: Guidelines for adult stroke rehabilitation and recovery: a
guideline for healthcare professionals from the American Heart Association/American Stroke
Association. Stroke 2016;47:e98–169
6. Stein J, Bettger JP, Sicklick A, et al: Use of a standardized assessment to predict rehabilitation
care after acute stroke. Arch Phys Med Rehabil 2015;96:210–7
7. Magdon-Ismail Z, Sicklick A, Hedeman R, et al: Selection of postacute stroke rehabilitation
facilities: a survey of discharge planners from the Northeast Cerebrovascular Consortium
(NECC) region. Medicine (Baltimore) 2016;95:e3206
S8 www.ajpmr.com
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Volume 102, Number 2 (Suppl), February 2023
8. Cormier DJ, Frantz MA, Rand E, et al: Physiatrist referral preferences for postacute stroke
rehabilitation. Medicine (Baltimore) 2016;95:e4356
9. Magdon-Ismail Z, Ledneva T, Sun M, et al: Factors associated with 1-year mortality after
discharge for acute stroke: what matters? Top Stroke Rehabil 2018;25:576–83
10. Liu H, Zhu C, Cao J, et al: Hospitalization costs among immobile patients with hemorrhagic
or ischemic stroke in China: a multicenter cross-sectional study. BMC Health Serv Res 2020;
20:905
11. Naito Y, Kamiya M, Morishima N, et al: Association between out-of-bed mobilization and
complications of immobility in acute phase of severe stroke: a retrospective observational
study. J Stroke Cerebrovasc Dis 2020;29:105112
12. Kortebein P: Rehabilitation for hospital-associated deconditioning. Am J Phys Med Rehabil
2009;88:66–77
13. Oyanagi K, Kitai T, Yoshimura Y, et al: Effect of early intensive rehabilitation on the clinical
outcomes of patients with acute stroke. Geriatr Gerontol Int 2021;21:623–8
14. Gordon NF, Gulanick M, Costa F, et al: Physical activity and exercise recommendations for
stroke survivors: an American Heart Association scientific statement from the Council on
Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the
Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and
Metabolism; and the Stroke Council. Stroke 2004;35:1230–40
15. Cuccurullo SJ, Fleming TK, Kostis WJ, et al: Impact of a stroke recovery program integrating
modified cardiac rehabilitation on all-cause mortality, cardiovascular performance and
functional performance. Am J Phys Med Rehabil 2019;98:953–63
16. Cuccurullo SJ, Fleming TK, Kostis JB, et al: Impact of modified cardiac rehabilitation within
a stroke recovery program on all-cause hospital readmissions. Am J Phys Med Rehabil 2022;
101:40–7
17. Cuccurullo SJ, Fleming TK, Zinonos S, et al: Stroke recovery program with modified cardiac
rehabilitation improves mortality, functional & cardiovascular performance.
J Stroke Cerebrovasc Dis 2022;31:106322
18. Kleindorfer DO, Towfighi A, Chaturvedi S, et al: 2021 guideline for the prevention of stroke
in patients with stroke and transient ischemic attack: a guideline from the American Heart
Association/American Stroke Association. Stroke 2021;52:e364–467
19. Duncan PW, Bushnell C, Sissine M, et al: Comprehensive stroke care and outcomes: time for
a paradigm shift. Stroke 2021;52:385–93
20. Raghavan P: Upper limb motor impairment after stroke. Phys Med Rehabil Clin N Am 2015;
26:599–610
21. Levin MF, Kleim JA, Wolf SL: What do motor “recovery” and “compensation” mean in
patients following stroke? Neurorehabil Neural Repair 2009;23:313–9
22. Stinear CM, Byblow WD, Ackerley SJ, et al: Predicting recovery potential for individual
stroke patients increases rehabilitation efficiency. Stroke 2017;48:1011–9
23. Prabhakaran S, Zarahn E, Riley C, et al: Inter-individual variability in the capacity for motor
recovery after ischemic stroke. Neurorehabil Neural Repair 2008;22:64–71
24. Carmichael ST: Emergent properties of neural repair: elemental biology to therapeutic
concepts. Ann Neurol 2016;79:895–906
25. Hayward KS, Kramer SF, Dalton EJ, et al: Timing and dose of upper limb motor intervention
after stroke: a systematic review. Stroke 2021;52:3706–17
26. Daly JJ, McCabe JP, Holcomb J, et al: Long-dose intensive therapy is necessary for strong,
clinically significant, upper limb functional gains and retained gains in severe/moderate
chronic stroke. Neurorehabil Neural Repair 2019;33:523–37
27. Ward NS, Brander F, Kelly K: Intensive upper limb neurorehabilitation in chronic stroke:
outcomes from the Queen Square programme. J Neurol Neurosurg Psychiatry 2019;90:
498–506
28. Mawase F, Cherry-Allen K, Xu J, et al: Pushing the rehabilitation boundaries: hand
motor impairment can be reduced in chronic stroke. Neurorehabil Neural Repair 2020;
34:733–45
29. Boissoneault C, Grimes T, Rose DK, et al: Innovative long-dose neurorehabilitation for
balance and mobility in chronic stroke: a preliminary case series. Brain Sci 2020;10:555
30. O’Keeffe R, Shirazi SY, Bilaloglu S, et al: Nonlinear functional muscle network based on
information theory tracks sensorimotor integration post stroke. Sci Rep 2022;12:13029
31. Dromerick AW, Geed S, Barth J, et al: Critical Period After Stroke Study (CPASS): a phase II
clinical trial testing an optimal time for motor recovery after stroke in humans.
Proc Natl Acad Sci U S A 2021;118:e2026676118
32. Brosseau L, Raman S, Fourn L, et al: Recovery time of independent poststroke abilities: part I.
Top Stroke Rehabil 2001;8:60–71
33. Brosseau L, Raman S, Fourn L, et al: Recovery time of independent poststroke life habits: part
II. Top Stroke Rehabil 2001;8:46–55
34. World Health Organization: International Classification of Functioning, Disability and
Health (ICF). Geneva, Switzerland, WHO, 2001
35. Forster A, Young J: Incidence and consequences of falls due to stroke: a systematic inquiry.
BMJ 1995;311:83–6
36. Fini NA, Holland AE, Keating J, et al: How physically active are people following stroke?
Systematic review and quantitative synthesis. Phys Ther 2017;97:707–17
37. Fini NA, Bernhardt J, Holland AE: Low gait speed is associated with low physical activity and
high sedentary time following stroke. Disabil Rehabil 2021;43:2001–8
38. Fini NA, Bernhardt J, Churilov L, et al: A 2-year longitudinal study of physical activity and
cardiovascular risk in survivors of stroke. Phys Ther 2021;101:pzaa205
© 2023 Wolters Kluwer Health, Inc. All rights reserved.
 Volume 102, Number 2 (Suppl), February 2023
39. Jorgensen HS, Pedersen PM, Kammersgaard L, et al: Epidemiology of stroke related
disability, in Duncan PW (ed): Clinics in Geriatric Medicine: Stroke. Philadelphia, PA, WB
Saunders, 1999:785–800
40. Espernberger KR, Fini NA, Peiris CL: Personal and social factors that influence physical
activity levels in community-dwelling stroke survivors: a systematic review of qualitative
literature. Clin Rehabil 2021;35:1044–55
41. Ashcroft SK, Ironside DD, Johnson L, et al: Effect of exercise on brain-derived neurotrophic factor in
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1A
stroke survivors: a systematic review and meta-analysis. Stroke 2022;53:3706–16
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/03/2023
© 2023 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Unified Model for Stroke Recovery
42. Palumbo A, Aluru V, Battaglia J, et al: Music upper limb therapy-integrated provides a feasible
enriched environment and reduces post-stroke depression: a pilot randomized controlled trial.
Am J Phys Med Rehabil 2022;101:937–46
43. Linder SM, Rosenfeldt AB, Davidson S, et al: Forced, not voluntary, aerobic exercise enhances
motor recovery in persons with chronic stroke. Neurorehabil Neural Repair 2019;33:681–90
44. Ploughman M, Eskes GA, Kelly LP, et al: Synergistic benefits of combined aerobic and
cognitive training on fluid intelligence and the role of IGF-1 in chronic stroke.
Neurorehabil Neural Repair 2019;33:199–212
www.ajpmr.com S9