Physical therapists attempt to achieve the ultimate goal of reducing disability and improving independence in stroke survivors by working with the patient to regain control over their motor functions, such as walking, standing or getting in and out of bed, and to teach them to safely compensate for any disabilities with the use of assistive devices, such as a wheelchair or cane.

However, the emphasis on compensatory strategies (like teaching patients how to cope in a wheelchair since being on their feet was thought to be impossible), has shifted to more forced-use activities with the theory that increased use of the affected extremity after stroke may promote recovery.

"Stroke rehab has been revolutionized in the last couple of years because of research that has come out," said Heather Hermeling, DPT, therapist supervisor at Spalding Rehabilitation Hospital in Denver, CO.

Each year about 700,000 people experience a stroke nationwide. Stroke is the third leading cause of death in the United States and the leading cause of serious, long-term disability in adults, according to the American Stroke Association.

Stroke can cause problems with movement, often down just one side of the body. All limbs can be affected, and while some recovery is common over time, about one third of people will have continuing problems.

Before recent advances in research, it was commonly believed that the amount of improvement patients could expect to see would happen in the first six months, with the most gains being made in the first 30 days to three months.

"Physiology was in the remodeling phase," Hermeling said. "What you were left with is what you would be. You wouldn't think there would be a lot of recovery, so you would teach them how to compensate."

The study of "neuroplasticity," a process the brain uses to adjust itself functionally by reorganizing the cortical maps, has been shown to contribute to stroke recovery. Neuroplasticity allows the neurons in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment.

This means progress can continue for six, or even 10 years, after a stroke. "The potential for recovery has changed a lot," Hermeling said.

Forced-Use Activities
Forced-use activities include constraint-induced movement therapy, which forces the use of the affected side by restraining the unaffected side. The therapist constrains the patient's unaffected arm in a sling, and the patient then uses his affected arm repetitively and intensively for two weeks.

Edward Taub, PhD, a professor of psychology at the University of Alabama in Birmingham, and his colleagues published the results in a 2006 edition of Stroke of a placebo-controlled trial of constraint-induced therapy they conducted in patients with mild to moderate chronic motor deficiency after stroke.

The constraint-induced therapy group received intensive training of the more affected upper extremity for six hours per day on 10 consecutive weekdays, restraint of the less affected extremity for a target of 90 percent of waking hours during the two-week treatment period, and application of a number of other techniques designed to produce transfer to the life situation. The placebo group received a program of physical fitness, cognitive and relaxation exercises for the same length of time and with the same amount of therapist interaction as the experimental group.

After constraint-induced therapy, patients showed large to very large improvements in the functional use of their more affected arm in their daily lives, the study showed. The changes persisted over the two years tested. Placebo subjects showed no significant changes.

The results support the efficacy of constraint-induced therapy for rehabilitating upper extremity motor function in patients with chronic stroke, the researchers concluded.

Another therapy aims to address the inability or an impaired ability to walk after stroke. Ongoing research studies are looking at whether walking on a treadmill, possibly with some body weight supported via a harness connected to an overhead support system, can be used to train walking.

Meeting demands
Indeed, stroke rehabilitation is leaning toward using evidence-based practice to have a positive and not negative influence, said Ola Iyewanrun, PT, a research physical therapist at Brooks Rehabilitation Hospital in Jacksonville, FL.

"The nervous system can recognize itself based on demands placed on it, including demands put by the patient and the PT," she said. "The nervous system needs demands in order to respond and will be responsive for as long as demands are placed on it."

For example, patients who spend most of the day sitting down will not place enough demands on their nervous system. However, if the patient practices getting up, reaching with the weak hand and trying various positions, the nervous system will respond and enable the person to continue to improve, within limit of the injury sustained, Iyewanrun said. "The level of independence is less likely to improve if patients are sedentary."

When incorporating strategies based on motor recovery, researchers also have found that patient compliance, and therefore progress, increases when patients have more of a role in their rehabilitation, from choosing therapies to determining treatment goals.

"When we as therapists are able to listen to what patients' goals are, it helps patients speed end results and work toward their goals," Iyewanrun said.

Stroke rehabilitation centers generally employ a continuum of care to increase patients' chances of a return to independence. Patients first receive approximately three hours of skilled therapy a day provided by a team of professionals, who become involved with patients based on their individual needs and impairments.

Before developing an individualized treatment plan, the PT will evaluate strength, endurance, range of motion, while also assessing gait abnormalities and sensory problems.

PTs help patients regain strength, balance, coordination and enduranc so they can walk, climb stairs, use a wheelchair and manage other physical activities that enhance mobility. Many patients then are referred to outpatient rehabilitation programs, upon discharge from the hospital, to continue their intensive rehabilitation.

PTs also will develop a home exercise program for each patient and instruct them and their caregivers how to perform, and they can work with caregivers to enable them to safely care for or assist with their mobility.

"More and more people are back in the community after having stroke, being able to function at a high level," Hermeling said.

Sarah Long is a frequent contributor to ADVANCE.


My husband doctor want him to do this contraint induce therapy. It has never been done here before. Where can we go and get this therapy for my husband. He had a stroke in Oct. 2006 he is 46 years old. We do not have much money becuase of all the medical bills. We have Federal Blue Cross and Blue Shield insurance Thank You

Muriel BruneauJuly 14, 2008
Nashua, NH


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