Stroke rehabilitation: Assignment 1

Ariana-Rose Begg 2271538

Patient centred stroke rehabilitation: neurological and functional rehabilitation for upper limb function, cognition, and mobility............................................1
Three common clinical signs and symptoms following stroke and evidence-based treatment of these symptoms (543 words)..............................................1
Concept Map............................................................................................................................................................................................................................. 3
Appendix 1: Information on Concept map provided for word count (1046 words)...................................................................................................................4
Patient centred rehabilitation................................................................................................................................................................................................ 4
0–3-month neurological recovery.......................................................................................................................................................................................... 4
On-going rehabilitation functional recovery 6 months-3 years.............................................................................................................................................5
Multidisciplinary team........................................................................................................................................................................................................... 7
References................................................................................................................................................................................................................................. 8

Patient centred stroke rehabilitation: neurological and functional rehabilitation for upper limb function,
cognition, and mobility.
Three common clinical signs and symptoms following stroke and evidence-based treatment of these symptoms (543 words)
Strokes can cause hypoxic cell damage, brain tissue death, and decreased neuronal activity in brain regions (Gavaret et. al, 2019). Survivors
may experience sensorimotor and cognitive impairments including:
1. Hemiparesis: unilateral motor impairment of upper limb (UL)
2. Hemiparesis: unilateral lower limb (LL) weakness + impaired mobility
3. Impaired cognition: reduced memory, learning, problem-solving, executive functioning, and fatigue.
Meaningful, repetitive, intensive, task-specific therapy targeting neuroplasticity and developing new neural pathways with strategies to
compensate for on-going deficits is recommended (Takeuchi and Izumi, 2013). Early rehabilitation ensures peak gains; however, gains are
possible years after a stroke (Teasell & Hussein, 2013b). Evidence supports individualised treatment by co-ordinated multidisciplinary teams

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(MDTs) with organised assessments, goal setting, interventions, reassessments, and discharge planning that includes strategies for continuity
of care and return to meaningful participation in everyday life (Wottrich AW, von 2007). Rehabilitation should be structured to provide as
much therapy as possible (Stroke Foundation, 2022). Acutely, in-patient rehabilitation is recommended, later, home-based rehabilitation may
be preferable to ensure specificity of practice and maintenance of abilities (Ward et. al 2003).
Upper limb impairment due to damage in motor and pre-motor cortexes and corticospinal tract (CST) is the most common disability after
stroke (Lin et. al, 2019). Therapists must consider brain imaging when setting goals and clinical interventions, as increased CST damage reduces
the likelihood of regaining full UL function (Lin et. al, 2019). Stroke Foundation guidelines (2022) recommend multidisciplinary interventions,
progressive resistance training, repetitive practice, CMIT, ESTIM and robotics in 1:1, group, and self-directed independent contexts. Regaining
UL function is a priority for survivors, carers and health professionals, and interventions should include component and whole practice of tasks
identified by the patient as important to participation in society (Langhammer & Verheyden, 2013). Acutely, rehabilitation should target
improved power, co-ordination, and functional outcomes, later, maintenance of available function is a priority, including educating patients
and caregivers that functional decline is likely if carers take over ADL tasks trained in rehab (Teasell & Hussein, 2013b).
Impaired mobility due to LL hemiparesis initially effects up to 2/3 of stroke patients. (Platz, 2021). For patients unable to walk, intensive
progressive gait training targeted at regaining abilities is recommended, for patients mobilising with help, the recommendation is task specific
training combined with motor imagery targeting speed, distance and balance with improvements measured by 10m walk test, 6MWT, Berg
and TUG (Platz, 2021). Stroke Foundation (2022) recommends task specific training, repetitive practice and ESTIM to improve strength, and
circuit class therapy, treadmill training, VR training, biofeedback, ESTIM and LL orthosis to improve mobility. Patients who are non-walkers are
likely to regain best functional recovery in the first 6 weeks, however functional gains can still result months after neurological recovery is
completed (Teasell & Hussein, 2013b).
Cognitive impairments present in 50-70% of stroke survivors (Platz, 2021), and improving cognition is a priority of patients and MDTs
(Langhammer & Verheyden, 2013). Stroke Foundation guidelines (2022) recommend screening by neuropsychologists/OTs or speech
pathologists, with cognitive training, individualised training strategies and memory aids to address deficits, and providing therapy in stroke
survivor’s usual environment (or similar) to encourage generalisation. Cognitive deficits impact long-term outcomes, so treatment and
education about symptom management should consider the impact of cognitive impairments on participation in treatment and daily life (Platz,
2021).

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Concept Map

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Appendix 1: Information on Concept map provided for word count (1046 words)
Patient centred rehabilitation
0–3-month neurological recovery
MDT need to ensure patients and caregivers are adequately prepared for the return home (Brown et. al. 2014)
Upper limb function
Short form: MDT Ax and Rx of strength, ROM, tone, subluxation, contracture, pain and swelling, current function and D/C goals
Long form:
MDT initial assessment of strength, ROM, co-ordination, tone, subluxation, contracture, pain and swelling, current function and discharge
goals will assist the team to formulate treatments.
OT: UL Rx with targeted exercises, robotics and ESTIM. For patients with some active wrist + finger extension CMIT 2hours per day for 2 weeks
plus restraint for at least 6 hours per day (Stroke Foundation, 2022). Compression gloves may be recommended for swelling.
PT: UL training during therapy including reach and grasp exercises and using affected UL in reaching outside of base of support. PT can assist
with placement of ESTIM and reinforce education on the importance of independent practice of UL exercises. PT may ensure care team is
aware of UL protection requirements e.g. collar and cuff/pillow support between therapy sessions and during transfers.
Psychologist/Social Workers may address concerns around grief and loss of roles and hobbies requiring upper limb function and manual
dexterity, address mood and motivation concerns impacting individual engagement with therapy and reinforce the benefits of mental practice.
Cognition
Short form: Cognitive screening and Ax to support D/C planning and treatment including MoCA, HADS-A, SADQ-H, FSS
Long form: Individualise communication strategies including written and visual info (Platz, 2021)
OT, Psychologist, Social worker work together to provide cognitive screening and assessment to support discharge destination and treatment
planning including MoCA, HADS-A, SADQ-H, FSS. They will provide information to patient and carers on potential impacts of impairments on
future functioning (Platz, 2021).

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Physiotherapists work with speech therapists and neuropsychologists to develop individualised communication strategies including written
and visual information to assist patients to overcome the impacts of cognitive impairment on successful engagement in physical therapy.
Speech therapist can assess aphasia and dysphasia to identify deficits and strategies and provide treatments including motoric-imitative +
cognitive linguistic treatments to improve use of emotional tone in speech, and semantic-based treatment to connect literal and metaphorical
senses and improve conversational comprehension.
The MDT can work together to develop systems of communication/memory aids e.g. notebooks/mobile phone alerts to ensure consistency of
messaging between patients, caregivers and the treating team.
Mobility
Short form: Ax strength, ROM, co-ordination, tone, contracture, pain, current function, discharge goals. Early and intense therapy targeting
part practice stepping, assisted mobility, transfers and ankle orthosis as indicated
Long form:
Physiotherapists assess strength, ROM, co-ordination, sensation, tone, contracture, pain and current function of the hemiparetic lower limb
and set discharge goals based with the patient and the team based on expected outcomes. Physiotherapy will target LL strength and co-
ordination for return to mobility including STS, standing balance, stepping practice and assisted mobility as appropriate. Therapists will work
with the patient to practice mobilisation and early exercise including treadmill walking to enhance physical function and shorten length of stay
(Langhammer & Verheyden, 2013), and prescribe lower limb orthoses as indicated.
Occupational therapy can encourage patients to SOOBIC for therapy, practice sit to stands, transfers and mobility, provide information on
expected prognosis based on mobility gains, and assist with sourcing adaptive equipment or home modification.
Mobility level will greatly influence functional abilities such as transfers on discharge, so the whole MDT should be involved in encouraging the
patient to engage in the repetitions needed to progress in the first 6 weeks as the level of function attained will impact discharge planning.
Nurses can also be encouraged to facilitate mobility when appropriate.
On-going rehabilitation functional recovery 6 months-3 years
Assist patient to set realistic participation goals: e.g. walk to a local cafe, order a coffee and drink it - may require input from whole MDT to
achieve this (Laver et. al 2020)

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Upper limb function
Occupation therapy can provide targeted programs including leisure therapy to increase participation in leisure activities. On-going MDT goal
setting to set task specific goals relevant to functional recovery in patient chosen ADLs/PADLs is an essential part of on-going therapy. For
example, PT, OT and speech therapist may all work on different aspects of the same complex task such as standing at the bathroom sink and
brushing teeth (standing balance/upper limb function/oral function).
MDT involvement may be reduced with onus moving to patient and carers to seek specialist engagement as functional deficits become
apparent or maintenance is required.
Cognition
Short form: MDT will screen for a treat subjective cognitive complaints and consider vocational rehabilitation and problem solving in the home
to improve participation in ADLs. Cognition may be a barrier to goal setting (Brown et. al,. 2014).
Long form:
OT/Neuropsychologist will screen and treat subjective cognitive complaints and consider more extensive neuropsychological assessment than
the MoCA e.g. CLCE-24 and provide neuropsychological and vocational rehabilitation based on the impact of cognitive impairments on daily life
(Platz, 2021).
Home rehabilitation is more effective when provided by an MDT (Speech/OT/PT/ Social Worker) to help the person maximise role fulfillment
and independence in the context of cognitive impairment, with collaborative planning to enable improved function when problems occur.
MDT will encourage the patient and the caregivers to think about problems and solutions and not just keep repeating the task (Wottrich et. al
2007). When a patient requires extensive assistance to perform an activity, all MDT members are encouraged to practice the same activity
with the patient.
Brief, structured exercise plans that combine strength, aerobic training, and balance to enhance cognitive performance gains and reduce the
burden of cognitive deficits can be provided by PT, PT and EP to be completed independently (Oberlin et. al 2017).
Mobility
Falls prevention: MDT interventions targeting practice of functional transfers in home environment (PT/OT) and home modifications (OT) are
essential for first visit safety and smooth transition home (Wottrich et. al 2007). Mobility interventions may move from part practice and gait
retraining to improving distance and endurance and walking on hills, ramps, and uneven ground, as well as dual tasking to improve dynamic

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balance with cognitive tasks. Physical activity and exercise prescription should be customised to maximise adherence and prevent
deconditioning and sedentary lifestyles (Billinger et al., 2014).
Multidisciplinary team
- Doctors,
- nurses,
- physiotherapists
- exercise physiologists
- occupational therapists
- speech pathologists
- dieticians
- social workers
- psychologists

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 References
Billinger SA, Arena R, Bernhardt J, et al. (2014). AHA/ASA Scientific Statement Physical: Activity and exercise recommendations for stroke
survivors. Stroke, 2014;45:2532–53. Retrieved November 25, 2014 from http://stroke.ahajournals.org/content/45/8/2532.full.
Brown, M., Levack, W., McPherson, K. M., Dean, S. G., Reed, K., Weatherall, M., & Taylor, W. J. (2014). Survival, momentum, and things that
make me “me”: patients’ perceptions of goal setting after stroke. Disability and Rehabilitation, 36(12), 1020–1026
Gavaret, Marchi, A., & Lefaucheur, J.-P. (2019). Clinical neurophysiology of stroke. Handbook of Clinical Neurology, 161, 109–119.
https://doi.org/10.1016/B978-0-444-64142-7.00044-8
Langhammer, B., & Verheyden, G. (2013). Stroke Rehabilitation: Issues for Physiotherapy and Physiotherapy Research to Improve Life after
Stroke. Physiotherapy Research International, 18(2), 65–69. https://doi-org.ezproxy.flinders.edu.au/10.1002/pri.1553
Laver, K., Halbert, J., Stewart, M., & Crotty, M. (2010). Patient readiness and ability to set recovery goals during the first 6 months after stroke.
Journal of Allied Health, 39(4), e149–e154.
Lin, Cloutier, A. M., Erler, K. S., Cassidy, J. M., Snider, S. B., Ranford, J., Parlman, K., Giatsidis, F., Burke, J. F., Schwamm, L. H., Finklestein, S. P.,
Hochberg, L. R., & Cramer, S. C. (2019). Corticospinal Tract Injury Estimated From Acute Stroke Imaging Predicts Upper Extremity Motor
Recovery After Stroke. Stroke (1970), 50(12), 3569–3577. https://doi.org/10.1161/STROKEAHA.119.025898
Oberlin LE, Waiwood AM, Cumming TB, Marsland AL, Bernhardt J, Erickson KI (2017) Effects of physical activity on poststroke cognitive
function: a meta-analysis of randomized controlled trials. Stroke 48(11):3093–3100
Platz. (2021). Clinical Pathways in Stroke Rehabilitation Evidence-based Clinical Practice Recommendations (1st ed. 2021.).
Stroke Foundation (2022). Clinical Guidelines for Stroke Management. Melbourne Australia.
Takeuchi N, Izumi S-I. (2013). Rehabilitation with poststroke motor recovery: A review with a focus on neural plasticity. Stroke Research and
Treatment, vol. 2013, Article ID 128641, 13 pages, 2013. doi:10.1155/2013/128641. Retrieved November 12, 2014 from
http://www.hindawi.com/journals/srt/2013/128641/.
Teasell R, Hussein N. (2013b). Background concepts in stroke rehabilitation. In: Evidence-Based Review of Stroke Rehabilitation. Retrieved
February 11, 2015 from http://www.ebrsr.com/sites/default/files/Chapter3_Background-Concepts_FINAL_16ed.pdf

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Ward, Severs, M., Dean, T., & Brooks, N. (2003). Care home versus hospital and own home environments for rehabilitation of older people.
Cochrane Database of Systematic Reviews, 2, CD003164–CD003164.
Wottrich AW, von Koch L, & Tham K. (2007). The meaning of rehabilitation in the home environment after acute stroke from the perspective of
a multiprofessional team...including commentary by Jensen GM. Physical Therapy, 87(6), 778–788. https://doi-
org.ezproxy.flinders.edu.au/10.2522/ptj.20060152

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