REHABILITATION IN THE ACUTE STROKE SETTING

The primary goals of rehabilitation in the acute setting involve:

• Prevention of medical complications
• Prevention of deconditioning and contractures
• Training of new skills
• Optimizing poststroke rehabilitation:
• Early assessment with standardized evaluations and validated assessment tools
• Early employment of evidence-based interventions relevant to individual patient needs
• Patient access to an experienced multidisciplinary rehabilitation team
• Ongoing medical management of risk factors and comorbidities
(Physiopedia, 2022b)

Physical and Occupational Therapy Assessment Tools

Standardized evaluations and valid assessment tools are essential for evaluating patients following a stroke in order to develop a comprehensive treatment plan. Both physical and occupational therapists employ many of the assessment tools listed in the tables below (Teasell & Salbach, 2019).

FUNCTIONAL CAPACITY ASSESSMENT TOOLS

Tool	Assesses for …
Stroke Impact Scale	Stroke recovery as measured in eight domains: strength, hand function, mobility, activities of daily living (ADLs), emotion, memory, communication, and social participation
Functional Independence Measure (FIM)	Physical and cognitive disability (to measure burden of care)
Alpha FIM Instrument	Motor and cognitive function
Modified Rankin Scale (mRS)	Rating global outcome
Barthel Index (BI) of Activities of Daily Living	Independence in self care
6-Minute Walk Test (6MWT)	Walking capacity and endurance
Functional Autonomy Measurement System (SMAF)	Functional independence
Activities of Daily Living (ADL) Index	Performance of basic ADLs and mobility tasks

MOTOR FUNCTION ASSESSMENT TOOLS

Tool	Assesses for …
Chedoke-McMaster Stroke Assessment Scale (CMSA)	Physical impairment and disability
Fugl-Meyer Assessment (FMA) of Motor Recovery after Stroke	Motor function in upper and lower extremity, balance, sensation, range of motion, and pain
Rivermead Motor Assessment (RMA)	Gross function in leg, trunk, and arm movement
Stroke Rehabilitation Assessment of Movement (STREAM)	Voluntary movement of upper and lower limbs and basic mobility

MOBILITY ASSESSMENT TOOLS

Tool	Assesses for …
Berg Balance Scale (BBS)	Balance
Functional Ambulation Categories (FAC)	Rating ambulation status
Mini BEST Test	Balance control
Rivermead Mobility Index (RMI)	Performance of functional activities
Timed Up and Go (TUG) test	Mobility and balance
Functional Reach Test (FRT)	Maximum distance the patient can reach forward while standing in a fixed position

UPPER EXTREMITY ASSESSMENT TOOLS

Tool	Assesses for …
Actional Research Arm Test (ARAT)	Grasp, rip, pinch, and gross movement
Box & Block Test (BBT)	Unilateral gross manual dexterity
Chedoke Arm and Hand Activity Inventory (CAHAI)	Arm and hand function while performing bilateral functional tasks
Nine Hole Peg Test (NHPT)	Manual dexterity
Wolf Motor Function Test (WMFT)	Upper extremity motor ability

VISUAL PERCEPTION AND NEGLECT ASSESSMENT TOOLS

Tool	Assesses for …
Behavioral Inattention Test (BIT)	Visual neglect
Line Bisection Test (LBT)	Unilateral spatial neglect
Motor-free Visual Perception Test (MPT)	Visual perception

Major Therapy Approaches

Several approaches can be used in the rehabilitation of patients following stroke, and it is not uncommon for elements of several different approaches to be used when treating a patient. Some common approaches include, but are not limited to:

Traditional therapy: Employs straightforward training in range of motion, strengthening, mobilization, gait and balance, and compensatory techniques.

Bobath concept: Involves neurodevelopmental training (NDT), which suppresses abnormal muscle patterns before normal patterns are introduced. Abnormal patterns are modified at proximal key points of control, such as neck, spine, shoulder, and pelvis.

Brunnstrom movement therapy: Involves central facilitation and aims to enhance specific synergies through the use of cutaneous/proprioceptive stimuli.

Proprioceptive neuromuscular facilitation (PNF): Aims to stimulate nerve/muscle/sensory receptors to evoke response through manual stimuli to increase ease of movement and promote function.

Sensorimotor therapy (Rood Approach): Uses cutaneous sensorimotor stimulation to modify muscle tone and voluntary activity.

Motor relearning program (Carr Approach): Uses cutaneous sensorimotor stimulation to modify muscle tone and voluntary activity.

Constraint-induced movement therapy (CIMT): Used to improve and increase the use of the more affected extremity while restricting the use of the less affected arm.

Functional electrical stimulation (FES): Used to improve strength in the upper and lower extremities; also assists in management of dependent peripheral edema and establishes early proprioceptive joint sense in sensory-compromised patients.

Electromyographic biofeedback (EMG-BF): Attempts to modify autonomic functions, pain, and motor disturbances through acquired volitional control using auditory, visual, and sensory clues.

Robotic devices: Helps therapists ensure that exercises are performed properly. They collect performance information and objectively measure progress. Examples include:

• LokomatPro Gait Trainer
• Erigo Pro tilt table
• Andago, which bridges the gap between treadmill and free walking
• Diego, for arm and shoulder rehabilitation
• PABO, which provides interactive therapies for the whole body, hands, fingers, arms, and legs
  (Bacharach, 2022)

Physical Therapy for Acute Stroke Rehab

Physical therapy is one of the core professional disciplines involved in stroke rehabilitation. Rehabilitation therapy typically begins in the acute-care hospital once the patient’s condition has stabilized, often within 48 hours following the stroke. The main goal of physical therapy is to help mobilize the patient’s return to activities at home, at work, and in the community. Treatment plans focus on improving mobility, addressing pain, and providing guidance on ways to prevent complications that may occur after a stroke.

PHYSICAL THERAPY ASSESSMENT

Following an acute stroke, physical therapists begin assessment by obtaining:

• History of the present illness
• Past medical history
• Standardized review of systems
• Social history
• List of medications being taken
• Family history
• Prior activity level
• History of any recent alterations in function prior to stroke
• Mobility issues
• Personal care ability and use of aids/devices to assist
• Cognition
• Communication
• Swallowing
• Pain
• Risk for fatigue
• Perceptions of poststroke abilities
  (Physiopedia, 2022b)

Physical examination includes objective testing of the following:

• Posture
• Passive range of motion
• Muscle strength
• Coordination
• Involuntary movements
• Muscle tone
• Deep tendon reflexes
• Sensation
• Functional activities
• Mobility, including bed mobility
• Transfers
• Sitting and standing balance
• Upper and lower limb function
• Stairs
• Gait
(Physiopedia, 2022b)

ACUTE CARE PHYSICAL THERAPY INTERVENTIONS

Early initiation of mobility-focused physical rehabilitation as soon as the patient is medically stabilized has been associated with decreased deconditioning, improved long-term functional outcomes, and decreased risk of hospital readmission.

In the acute care setting, evaluation and interventions provided by physical therapists may include any of the following, depending on a patient’s functional deficits and ongoing needs:

• Positioning/bed mobility: Physical therapists advise on safe and correct positioning of the patient in multiple positions, including supine, side-lying (on both affected and unaffected sides), and sitting, in order to avoid injury and promote the patient’s ability to self-mobilize. Early bed mobility training may include teaching patients how to roll side-to-side, transition from supine to/from sitting, sit supported in bed, and sit supported out of bed (with or without back support). Proper positioning can help reduce muscle pain, spasms, slowness, or stiffness that can occur following a stroke.
• Range-of-motion (ROM) exercises: Both passive and active exercises may be initiated early and performed daily in order to promote and maintain joint mobility, protect compromised joints (such as a subluxed shoulder), prevent contractures, increase circulation to extremities, and decrease vascular complications of immobility. ROM exercises may be performed more frequently if patients have increased risk of joint contractures. Effective positioning strategies are important in maintaining soft tissue length and to encourage proper joint alignment. Patients may also be taught ROM self-activities.
• Managing spasticity: If spasticity is present, early mobilization and daily stretching may be employed to maintain length of spastic muscles and soft tissues and promote optimal positioning. Modalities may include application of cold or heat, massage, and electrical stimulation.
• Facilitating upright sitting: Sitting upright is an important way to build endurance, provide maximum stimulation, and give the patient a sense of normalcy during the acute care phase. Early training in sitting focuses on achieving a symmetrical posture with optimal spine and pelvic alignment.
• Exercises to improve respiratory and circulatory functions: If not medically contraindicated, exercises to optimize respiratory and circulatory function may be initiated during this phase. Exercises may include deep breathing and coughing; chest expansion exercises; ankle pumps; and active, active-assisted, or passive upper and/or lower extremity exercises.
• Decubiti prevention measures: In order to prevent the complication of pressure injury/ulcers, physical therapists work with and make recommendations to the interdisciplinary team to ensure that patients are properly positioned and that pressure points are protected by appropriate padding, cushioning, and/or unweighting. PT may advise on the use of pressure-reducing devices such specialized beds/mattresses, foot/ankle positioners, or pressure-relieving wheelchair cushions (such as those with a gel or air-cell core). Improving a patient’s ability to independently mobilize is one of the more important physical therapy interventions with regard to preventing pressure injuries.
• Transfer techniques: Physical therapy interventions include teaching the patient how to safely transfer between multiple types of surfaces, including bed to/from chair and sitting to/from standing. Physical therapists also advise clinical staff on how to appropriately support/assist the patient during transfers (including demonstrating and performing correct transfer technique using assistive devices such as gait belts, assistive devices, or mechanical lifts) as well as recommend the appropriate level of assistance to be used.
• Balance improvement measures: As allowed by a patient’s functional mobility status, physical therapists may assist with early-stage balance training activities, including specific bed exercises (e.g., pelvic bridging), sitting on the edge of bed (with or without external support), standing (with or without support), and progressing to ambulation as appropriate. Improving static and dynamic balance, along with improved ability to ambulate (or self-propel a wheelchair) can lead to greater independence and overall well-being as a patient prepares for discharge.
• Balance and walking speed: Backward walking training (BWT) has been shown to significantly improve motor functions, including the 10-meter walk test (10MWT), cadence, Berg Balance Scale (BBS), paretic step length, and stride length (Wen & Wang, 2022).
• Deconditioning prevention measures: To prevent deconditioning, physical therapists make recommendations for and encourage early bed mobility and as much out-of-bed time as medically appropriate and tolerated by the patient. Such activities may include side-to-side rolling, transitioning from supine to/from sitting, sitting upright in an appropriate chair, transferring sit to/from stand, and (when appropriate) ambulation with appropriate assistive devices or propelling a wheelchair.
• Assistive device training: Prior to discharge, physical therapists may recommend and/or train the patient in the use of appropriate assistive devices, such as:
• Wheelchairs
• Walkers (rolling, standard, hemi-, etc.)
• Canes (straight, quadripod, etc.)
• Orthoses (i.e., when foot drop is present)
• Any devices previously used by the patient (such as orthotics, prosthetics, etc.)
• Patient/family education: Physical therapists work with family members/caregivers in order to provide training in how to help with appropriate exercises for the patient as well as how to safely help the patient with functional mobility at home. They also provide education about the physical effects of the stroke and what continued rehabilitation may be able to accomplish for the patient.
• Discharge planning: Planning for discharge from inpatient rehabilitation begins on admission. Throughout the hospitalization, physical therapists continually reassess the patient’s functional mobility status in an effort to assist in determining the most appropriate setting for the next level of care. The physical therapist may make a home visit prior to discharge to determine the need for architectural and/or other safety modifications.
  (NINDS, 2020; O’Sullivan et al., 2019; Bruno-Petrina, 2021; Rose et al., 2018)

Occupational Therapy for Acute Stroke Rehab

Occupational therapy plays a significant role in acute-care settings by facilitating early mobilization, improving function, preventing further decline, and coordinating care, including transition and discharge planning.

Treatment approaches are aimed to meet the ultimate goal of maximizing function and independence. They include:

• Rehabilitating and restoring function using physical, cognitive, perceptual, and functional activities
• Teaching restorative or compensatory techniques with or without the use of adaptive equipment, as appropriate
• Providing education on energy conservation techniques that address self-care, functional ability, or therapeutic exercise
• Recommending adaptive equipment and home modifications, if needed
  (Stromsdorfer, 2021)

OCCUPATIONAL THERAPY ASSESSMENT

The occupational therapist (OT) assesses a person’s abilities, including level of functional independence, perceptual-cognitive skills, sensory-motor skills, communication skills, quality of life, and levels of anxiety and/or depression. Elements of an occupational therapy assessment include:

• Interviews with the patient and/or family to establish the patient’s prior life roles and the tasks and activities involved in those roles
• Analysis of prehospitalization roles and the patient’s likelihood of resuming them
• Observation of the patient’s abilities to perform personal self-care (e.g., showering, dressing, toileting, grooming, eating)
• Identifying what the patient needs and wants to do, including the supports and barriers
• Visual-perceptual screening for impairments that can interfere with the ability to organize, interpret, and give meaning to information that is seen, impacting the ability to learn; assessing visual fields, convergence, and oculomotor abilities
• Memory, cognition, and executive functioning screening to determine the impact of changes on abilities to resume daily functioning
• Sensory and motor assessments, with particular emphasis on upper limb and hand function, functional mobility, and transfers

Assessment tools may include:

• Katz Index of Independence in Activities Daily Living provides a measurement of ability to perform independent activities that are part of the daily routine.
• Executive Function Performance Test (EFPT) assesses how a patient completes four basic tasks.
• Sensory Processing Measure, second edition, (SPM-2) provides a complete picture of sensory integration and processing in multiple environments and provides additional descriptive clinical information on processing vulnerability within each sensory system.
  (Neurolutions, 2022)

ACUTE CARE OCCUPATIONAL THERAPY INTERVENTIONS

Occupational intervention in acute stroke care initially is directed at sensory-motor and perceptual-cognitive performance skills, as well as re-education and training in the basic and instrumental activities of daily living (ADLs and IADLs). Later, interventions oriented more toward the social and labor integration of the person is considered.

Occupational therapy intervenes using specific procedures and activities to develop, maintain, improve, and/or recover the performance of the following functions and activities:

• Basic and instrumental ADLs
• Health management
• Rest and sleep
• Education
• Work
• Play
• Performance skills (motor, sensory-perceptual, emotional regulation, social, and communication)
  (Garcia-Pérez et al., 2021)

Occupational therapy interventions in the acute stage include:

• Positioning and seating: Correct positioning in good body alignment to reduce the risk of:
• Aspiration
• Shoulder pain
• Pressure areas
• Deep vein thrombosis and pulmonary embolism
• Contractures
• Chronic pain in affected joints
• Muscle spasticity
• Extremity swelling
• Upper limb positioning: Addressing upper limb positioning to prevent shoulder trauma, lessen pain, reduce swelling, and encourage independence in feeding and other self-care activities
• Mobilization techniques: Utilizing positioning, turning, and transferring techniques to assist with mobility, and employing neuromuscular re-education, trunk stabilization, and balance activities to improve the patient’s ability to move in and out of bed and maintain an upright posture necessary to perform self-care
• Prevention of pressure injuries (decubiti): Utilizing methods to prevent pressure injuries, such as:
• Cushions and padding
• Barrier sprays
• Lubricants
• Special mattresses
• Protective dressings
• Splinting
• Use of positioning devices
• ADLs: Providing training in self-care activities (e.g., bathing, dressing) with adaptive or durable medical equipment and/or compensatory techniques if needed, such as linking behaviors that naturally go together, providing cueing, focusing on one task or step at a time and completing it before moving on to the next, substituting hook-and-loop fasteners (e.g., Velcro) for buttons on clothing, etc.
• Cognition and perception: Addressing cognitive and perceptual deficits, including compensatory techniques
• Assistive and adaptive devices and techniques: Providing training in the use of upper-extremity adaptive devices (i.e., for eating, bathing, grooming, and transferring) and wheelchair management
• Management of shoulder pain: Strategies for protecting the joint and reducing pain, including:
• Use of a neurologic support (e.g., GivMohr sling) to promote proper upper extremity positioning and arm swing (which also prevents the limitations that may occur when using a traditional orthopedic sling)
• Use of support while in the wheelchair to manage the affected side to avoid pain and prevent subluxation
• Discharge planning: Making recommendations for ongoing rehab in settings appropriate to the level of the patient’s rehabilitation needs, including inpatient, outpatient, skilled nursing, home health, community, nontraditional, or other postacute settings, according to the patient’s ability level and stroke severity

Speech-Language Therapy for Acute Stroke Rehab

Speech-language therapy is another core element of stroke rehabilitation and has a key role in the identification, assessment, and management of potentially life-threatening eating, drinking, and swallowing problems (dysphagia) and the development of other means of communication. Recovery of language skills is usually a slow process, and although most people make significant progress, few people regain full pre-injury communication levels.

SPEECH AND LANGUAGE SWALLOWING ASSESSMENT

All stroke patients are screened at bedside for dysphagia before being given food or fluids. Tools used by speech-language therapists to assess swallowing include:

• Mann Assessment of Swallowing Ability (MASA): This tool was first introduced to identify dysphagia in acute-stage stroke patients. It is also used as a screening tool in any dependent older adult.
• Acute Stroke Dysphagia Screen: This is an easily administered and reliable tool used to detect both dysphagia and aspiration risk in acute stroke patients.
• Victorian Dysphagia Screening Model ASSIST Tool: This tool is applied by professionals who have completed an approved training in dysphagia screening and recommended for use in the presence of persistent acute stroke symptoms.
• Swallowing Ability and Function Evaluation: This test evaluates swallowing; before it is administered, a baseline evaluation of cognition and proper motor function are obtained.
  (Tiwana & Bordoni, 2021)

Patients with suspected dysphagia may require additional instrumental assessment to examine the impact of swallowing anatomy and physiology on clinical presentation. Patients may also require further assessment or reassessment depending on changes in functional or medical status, including the video fluoroscopic swallowing study (VFSS) or the flexible endoscopic evaluation of swallowing (FEES), sometimes called fiber-optic endoscopic evaluation of swallowing.

Difficulty swallowing may be caused by delayed swallowing reflexes, inefficient use of the tongue, and inability to detect food lodged in the cheeks after swallowing.

DYSPHAGIA INTERVENTIONS

A speech-language pathologist can work with an individual to devise strategies to overcome or minimize this deficit once the reason has been determined. A simple change of body position during eating can make a significant difference. A food’s texture can be altered to make swallowing easier; for example, thin liquids can be thickened to prevent choking. A change in eating habits, such as taking small bites and chewing slowly, may also help alleviate dysphagia. Other interventions may include:

• Utilizing sensory stimulation for heightened sensory input
• Utilizing therapeutic maneuvers (e.g., Mendelsohn maneuver, supraglottic swallow)
• Utilizing exercise programs (tongue resistance, ROM, tongue base, chewing)
  (Neurolutions, 2022; ASHA, 2019)

SPEECH-LANGUAGE INTERVENTIONS

Strokes can result in difficulties with a patient’s ability to communicate ideas, needs, and feelings, which may include:

• Apraxia: Difficulty or inability to move the mouth and tongue to speak
• Aphasia: Impaired language, affecting production or comprehension of speech and ability to read or write
• Dysarthria: Impaired intelligibility of speech as a result of weakness, paralysis, or incoordination of speech musculature
• Cognitive deficits: Problems with attention, memory, perception, insight and judgment, organization, processing speed, problem-solving, reasoning, and executive functioning

Speech and language therapy aims to improve the ability to communicate by restoring as much language as possible, teaching the individual how to make up for lost language skills and finding other methods of communicating. Studies have found that therapy is most effective when it begins soon after the brain injury.

Specific exercises, guidance, explanations, techniques, or psychological support can all be used to treat dysarthria, depending on the individual. Some interventions are:

• Breathing exercises, to enhance breath support and control
• Nonspeech motions, to improve oral muscular strength, speed, and accuracy
• Text-to-speech tools as well as phonetic symbols, to summon out letters or words
• Instruction and education about dysarthria
• Collaboration with communication partners
• Involvement in communication support groups

For those with cognitive communication deficits, interventions may include:

• Using exercises or software to retrain discrete cognitive processes such as attention
• Using internal memory strategies or spaced retrieval training to solidify memories
• Completing practice tasks that are difficult in order to build independence
• Using external strategies for improving memory (e.g., memory books, smartphone apps)
• Education for patient and family
  (Maratab et al., 2022; TactusTherapy, 2022)