Recovery and rehabilitation after stroke

Some degree of recovery occurs in the majority of patients after stroke, and complete recovery is possible although the prognosis is difficult to predict in an individual patient. Rehabilitation to aid recovery and enable the patient to develop strategies for coping with disability forms the mainstay of treatment after the acute stroke period. 

Approximately two-thirds of stroke survivors become independent at one year, with little difference between ischemic or hemorrhagic strokes. However, within the ischemic group, only about 5% of patients with infarction of the whole middle cerebral artery territory are alive and independent at a year post-stroke, compared with 50% of those with more restricted infarcts (Table 16.1) (Bamford et al. 1990). Approximately 90% of stroke survivors return home, leaving only a small proportion in institutional care, but because stroke is so common, their absolute number is large (Legh-Smith et al. 1986 Chuang et al. 2005). 

The mechanisms of recovery are incompletely understood. Acute resolution of edema and recanalization of occluded vessels leading to resolution of penumbral dysfunction may contribute. In the subacute phase, changes in neuronal networks and neuronal plasticity are important (Kreisel et al. 2007 Nudo 2007). The mechanisms share similarities with those involved in learning and memory. The rate of recovery of all impairments is maximal in the first few weeks, slows down after two or three months and probably stops at about 6-12 months post-stroke (Pedersen et al. 1995 Kreisel et al. 2007). Later improvement in functional abilities, and particularly in social activities, is probably more to do with adaptation to disability and minimizing handicap rather than further recovery of physical impairments. Impaired quality of life is common even when patients appear to be Uttle disabled. 

Stroke rehabilitation attempts to restore patients to their previous physical, mental and social capability (Langton Hewer 1990 Brandstater 2005). Rehabilitation approaches include restoration of previous function, compensation by increasing function for a given impairment, environmental modification, prevention of complications such as recurrent stroke or shoulder pain, and maintenance or prevention of deterioration. Achieving optimal 

There are insufficient data to determine which patient groups benefit most from rehabilitation. Although severely affected patients benefit from rehabilitation, and in fact receive the most inpatient and outpatient therapy, they have the worst functional outcomes (Alexander et al. 2001). Therefore, it is unclear at present how best to target the available rehabilitation resources most efficiently. 

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Wade DT, Wood VA, Heller A et al. (1987). Walking after stroke. Measurement and recovery over the first 3 months. Scandinavian Journal of Rehabilitation Medicine 19 25-30... 

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