Definition and Overview
Stroke rehabilitation is a systematic and multidisciplinary treatment process to recover as much of the function damaged by stroke as possible, adapt to residual disability, and improve quality of life.
Worldwide, stroke is a leading cause of disability in adults. Approximately 80% of survivors remain with one or more functional disabilities, and rehabilitation is essential for independent daily living. A Cochrane review confirmed that multidisciplinary rehabilitation in the stroke unit significantly reduces mortality and long-term dependency.
The basis of neuroplasticity
The biological basis of stroke rehabilitation is neuroplasticity. The brain has the ability to recover function after injury through reorganization of surrounding neural networks, formation of new synaptic connections, and compensatory activity in the contralateral cerebral hemisphere.
Neuroplasticity is most active in the early weeks and months after stroke. Providing appropriate stimulation and repetitive training during this period can maximize neuroplasticity and improve the speed and extent of recovery. The ‘use it or lose it’ principle is the core of rehabilitation.
early rehabilitation
It is recommended that rehabilitation begin within 24 to 48 hours of onset in a stroke intensive care unit. Research results are somewhat mixed regarding the effectiveness of very early mobilization (VEM), but it is positive for preventing complications (pneumonia, deep vein thrombosis, bedsores) and long-term functional recovery.
The subacute period (2 weeks to 3 months after onset) after the acute period is the period when neural plasticity is most active, and intensive rehabilitation during this period is the key to functional recovery. Even in the chronic phase (3 months after onset), continuous improvement is possible through consistent training.
Components of Rehabilitation
physical therapy
Neurodevelopmental therapy (NDT), constraint-induced movement therapy (CIMT), and task-specific training are the main approaches. In upper limb paralysis rehabilitation, CIMT is a powerful method to induce intensive use of the paralyzed arm, and is effective in improving function in patients with mild to moderate paralysis. Weight-bearing treadmill gait training is also used for gait rehabilitation.
occupational therapy
Training of activities of daily living (ADL) is key. Eating, personal hygiene, dressing, and moving movements are trained, and the use of assistive tools (orthotics, modified utensils, etc.) is taught. It also includes training in fine hand movements.
speech therapy
Repetitive language task training and melodic intonation therapy are used in aphasia rehabilitation. Dietary adjustments and swallowing training are provided for rehabilitation of swallowing disorders (difficulty swallowing), and play a key role in preventing aspiration pneumonia.
cognitive rehabilitation
Cognitive impairment (deterioration in attention, memory, and executive function) after stroke occurs in approximately 20-60% of cases. Cognitive training programs, compensatory strategy training, and computer-based cognitive rehabilitation are utilized.
The role of neuromodulation therapy
Repetitive transcranial magnetic stimulation (rTMS) helps reactivate the brain on the injured side by controlling hyperinhibition in the motor cortex on the opposite side of the injured area. In clinical studies, rTMS combined rehabilitation was reported to be effective in improving upper extremity motor function, language function, and depressive symptoms. Transcranial direct current stimulation (tDCS) is also used as an adjunct to motor rehabilitation and cognitive rehabilitation.
A large study found that robot-assisted therapy was similar to physical therapy in upper extremity rehabilitation for patients with chronic stroke, but had limited additional benefits. Virtual reality training helps improve rehabilitation motivation by providing a repetitive and reward-oriented training environment.
Autonomic dysfunction after stroke
After stroke, autonomic dysfunction occurs in approximately 50-80% of cases, and decreased heart rate variability (HRV), orthostatic hypotension, and heart rate abnormalities are common. Autonomic abnormalities reduce the ability to participate in rehabilitation and increase the risk of falling, so evaluation and management are necessary during the rehabilitation process.
Managing Depression After Stroke
Post-stroke depression occurs in approximately 30-40% of survivors and impedes participation in rehabilitation and functional recovery. SSRI (sertraline, fluoxetine) antidepressants are effective in treating depression after stroke, and some studies have shown that they are helpful in recovering motor function. Cognitive behavioral therapy, mindfulness-based therapy, and social support also play an important role.