1/9/12 Motor Recover In Stroke

Motor Recover In Stroke

A :A B -P , MD, P D; C E :D IC , MD, MS ...

U :D 6, 2011

Recover Considerations
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1/9/12 Motor Recover In Stroke
functioning. A patient demonstrating this form of recovery presents with improvements in motor control, language
ability, or other primary neurologic functions.

The second type of recovery demonstrated by stroke patients is the improved ability to perform daily functions
within the limitations of their physical impairments. A patient who has sensorimotor, cognitive, or behavioral
deficits resulting from stroke may regain the capacity to carry out activities of daily living (ADL), such as feeding
himself/herself, dressing, bathing, and toileting, even if some degree of residual physical impairment remains.

The ability to perform these tasks can improve through adaptation and training in the presence or absence of
natural neurologic recovery, which is thought to be the element of recovery on which rehabilitation exerts the
greatest effect.

Hemiparesis and motor recovery have been the most studied of all stroke impairments. As many as 88% of
patients with acute stroke have hemiparesis.

In a classic report, Twitchell described in detail the pattern of motor recovery following stroke.[1] At onset, the
upper extremity (UE) is more involved than the lower extremity (LE), and eventual motor recovery in the UE is less
than in the LE. The severity of UE weakness at onset and the timing of the return of movement in the hand are
important predictors of eventual motor recovery in the UE. The prognosis for return of useful hand function is
unfavorable when UE paralysis is complete at onset or grasp strength is not measurable by 4 weeks.

However, as many as 9% of patients with severe UE weakness at onset may gain good recovery of hand function.
As many as 70% of patients showing some motor recovery in the hand by 4 weeks make a full or good recovery.
Full recovery, when it occurs, usually is complete within 3 months of onset.

Bard and Hirshberg asserted that if no initial motion is noticed during the first 3 weeks or if motion in one segment
is not followed within a week by the appearance of motion in a second segment, the prognosis for recovery of full
motion is not favorable.

Although most recovery from stroke takes place in the first 3 months, and only minor additional measurable
improvement occurs after the 6 months following onset, recovery may continue over a longer period of time in
some patients who have significant partial return of voluntary movement.

Criteria for admission to a comprehensive rehabilitation program

Criteria for a patient s admission to a comprehensive rehabilitation program may include the following:

Stable neurologic status

Significant persisting neurologic deficit
Identified disability affecting at least 2 of 5 functions, including mobility, self-care activities, communication,
bowel or bladder control, and swallowing
Sufficient cognitive function to learn
Sufficient communicative ability to engage with therapists
Physical ability to tolerate the active program
Achievable therapeutic goals

Theories of Recover
One theory of motor recovery is that collateral sprouting from intact cells to the denervated region occurs after
some or all input has been destroyed.

Another theory suggests that there is an unmasking of neural pathways and synapses that are not normally used
but that can be called upon when the dominant system fails (excitability to capture effects of remaining input).

Mechanisms of Recover
The first recovery mechanism is resolution of harmful local factors, which generally accounts for early spontaneous
improvement after stroke (usually within the first 3-6 mo). These processes include resolution of local edema,

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Pattern of Disabilit
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Pattern of Recover
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Recover of function in the UEs

Recovery of UE flexor synergy occurs as follows:

Shoulder flexion - 6-33 days

Elbow flexion - 1-6 days later
Finger and wrist flexion - 1-13 days later
Shoulder adduction/internal rotation

Clinically, flexor synergy can also present as follows:

Scapula retraction/elevation
Shoulder abduction (90°)/external rotation
Elbow flexion (acute angle)
Forearm supination (full range)

Recovery of UE extensor synergy occurs as follows:

Shoulder
Elbow
Wrist/finger extension

Clinically, extensor synergy presents as follows:

Scapula protraction
Humerus flexion/internal rotation
Elbow extension
Forearm pronation

In a study of 188 patients with stroke, Nijland et al found that assessment of finger extension and shoulder
abduction within 72 hours after stroke can help to predict upper limb recovery. If, by the second day following
stroke, patients in whom upper limb motor function was affected were capable of some voluntary extension of the
fingers and some abduction of the hemiplegic shoulder, there was a 0.98 probability that they would regain some
dexterity by 6 months.[2]

Patients with no such voluntary movement on the second day, according to the study, had only a 0.25 probability
of regaining dexterity by 6 months. Full recovery at 6 months was achieved in 60% of patients with some early
finger extension.

Recover of function in the LEs

Recovery of LE flexor synergy occurs as follows:

Hip flexion/adduction - 1-31 days

Knee flexion - 1-2 days later
Ankle/toe dorsiflexion - 25-90 days

LE extensor synergy is recovered first in hip/knee extension and then in ankle plantar flexion.

PT Options in Stroke
Rehabilitation should include physical therapy (PT) that is directed at specific training of skills and at functional
training.[3] Therapy should be given with sufficient intensity to promote skill acquisition. Major theories of
rehabilitation training include the following:

Traditional therapy
Bobath Concept Neurodevelopmental training
Proprioceptive neuromuscular facilitation
Brunnstrom

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Traditional therap

This form of therapy employs range-of-motion (ROM), strengthening, mobilization, and compensatory techniques.
The process of mental practice may also be used to improve the performance of certain activities.[4] This is when a
patient mentally rehearses an action without physically performing the action. Current evidence is not clear on
whether this practice, in conjunction with physical practice, actually improves motor capacity of the upper limb
region. Further studies are required.

Bobath concept

According to the Bobath concept, muscle patterns, not isolated movements, are used for motion. The theory
states that persons with motor deficiencies following stroke are unable to direct nervous impulses to muscles in
the different combinations used by persons with an intact central nervous system (CNS).

The therapy, therefore, is meant to suppress abnormal muscle patterns before normal patterns are introduced.
Abnormal patterns are modified at proximal key points of control, such as the neck, spine, shoulder, and pelvis.

Proprioceptive neuromuscular facilitation

This form of therapy aims to stimulate nerve/muscle/sensory receptors to evoke response through manual stimuli
to increase ease of movement and promote function.

Brunnstrom movement therap

This therapy involves central facilitation using Twitchell's recovery. It aims to enhance specific synergies through
the use of cutaneous/proprioceptive stimuli.

Studies

Every patient should avoid strenuous exercise after stroke, but it is a good idea to participate in an individualized
exercise program. At 1 year post stroke, improvement in functional walking ability was seen in stroke patients who
underwent either locomotor training, including body weight supported treadmill, or a progressive home exercise
program supervised by a physical therapist. No significant differences in improvement were found between the two
groups.[5] Reports in the literature state that for young stroke survivors who participated in an aerobic fitness
program, improvement in fitness levels, ambulatory speed, and life satisfaction was statistically significant.

Results from a randomized, controlled, assessor-blinded study indicated that even long after a stroke, kinesthetic
ability training, administered in combination with a conventional rehabilitation program, can improve balance in
hemiparetic stroke patients.[6]

The inclusion of breathing retraining (BRT) and inspiratory muscle training (IMT) in the rehabilitation program of
patients who have suffered a stroke can result in improved respiratory muscle function, exercise capacity, and
quality of life, according to a study by Sutbeyaz et al. In this study, patients received BRT and IMT training for half
an hour daily, 6 times a week for 6 weeks.[7]

Results from a systematic review indicate that modified constraint-induced movement therapy (CIMT) is more
effective than traditional rehabilitation in reducing a patient's disability level.[8] It can improve upper extremity ability
and increase movement spontaneity. Further studies are needed on CIMT s effectiveness in kinematic analysis.

In a pilot, randomized, clinical trial, with a 6-month follow-up, the practicality and efficacy of conventional
neurological therapy, constraint-induced therapy, and therapeutic climbing to improve minimal-to-moderate arm
and hand function in stroke patients was evaluated. The study concluded that improvement of arm and hand
function in the intermediate term was best achieved using the constraint-induced therapy approach.[9]

Occupational Therap in Stroke

Most patients with significant neurologic impairment who survive a stroke are dependent on others for performance
of basic ADL (ie, bathing, dressing, feeding, toileting, grooming, transfers). The capacity of individuals to perform
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he e ac i i ie a i c ed di abi i a i g ca e , ch a he F c i a I de e de ce Mea e.
A a a ie h i ed e f a ce f ADL a ec e cc .

M i e e i ed i he fi 6 h ,a h gh a a a 5% f a ie h c i ed ea ab e
i e e 12 h e . O he a ie a h ef ci a i e e be d6
h , e e h gh he di abi i ca e a fai de ec f he i e e beca e f hei i i ed
e i i i a he e e d f he f c i a a ge.

Re f he e e f f c i a i de e de ce e e a eached b e a ie af e ec e a f e
a h a he . Thi a iabi i bab ef ec diffe e ce be ee d ai , e h d f ea e ,
f - , a d da a e i g. I e , 47-76% f a ie achie e a ia a i de e de ce i he
ef a ce f ADL.

M a h h ha e a e ed de e i e hich fac edic i a e ADL f c i a c e ha e ed

i a ia e a a i . Of he a i de e de a iab e e ed, h e i ed be ha e bee e ed ha e he
i f e ce c e. H e e , a f he e fac ha e bee h edic c e a
a i ica i e e d . Fac edic i g ADL c e i c de he f i g:

Ad a ced age
C bidi ie
M ca dia i fa c i
Diabe e e i
Se e e e
Se e e ea e
P i i g ba a ce
Vi a ia defici
Me a cha ge
I c i e ce
L i i ia ADL c e
De a i i i ia i g ehabi i a i f i g e

Aphasia Therap
A i ae e hi d f a ie i h ac e e ha e c i ica fea e f a ha ia. La g age f c i i a
f he e a ie i e , a d, a 6 h e af e e, 12-18% f a ie ha e ide ifiab e
a ha ia.

S i bec a d c eag e e ed ha a ie i h a ha ia c i e h e aei e e i a g age

f ci ee e ha 1 ea af e e.

Pa ie h a e c a ified i i ia a ha i g B ca a ha ia ha e a iab e c e . I a ie i h a ge
he i he e e i , B ca a ha ia e i i h i e ec e . Pa ie ih a e e i c fi ed he
ei f a be f e h ea ge i ei e e , b he i ai e a e ei a i de f
f a ha ia i h a ia a d diffic fi di g d . Pa ie i h g ba a ha ia e d ge , ih
c ehe i fe i i g e ha e e i e abi i d e .

The c ica i e abi i f a ie h i i ia ha e g ba a ha ia i e e a ge e i d f i e,

a ea e e . Pa ie i h g ba a ha ia a cia ed i h a ge e i a h i
ec e , b ec e a be i e g d i a ie ih a e e i . The e e f a g age ec e
a cia ed i h We ic e a ha ia i a iab e.

Associated Conditions
M a ie ih e h de g ehabi i a i ha e a he a cia ed edica c di i ha e i e
fe i a a e i . The e be igh be ee i i g edica i e e ha ece i a e g i g ca e (eg,
h e e i , diabe e e i [DM]), ec da ec ica i (eg, dee e h b i ,
e ia), ac e e e ace ba i f ee i i g ch ic di ea e ( ch a a gi a i a a ie ih
i che ic hea di ea e).
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Management of these conditions can constitute major portions of the rehabilitation effort. Some patients may be
more disabled by certain associated comorbid diseases than by the stroke itself.

The occurrence of these associated conditions has several implications for management of stroke cases during
and after rehabilitation. First, these problems can detract from the benefits of rehabilitation. Some medical
problems, such as heart disease, have been found to affect the course and outcome of rehabilitation adversely
following a stroke. Intercurrent medical complications can limit the patient's ability to participate in therapeutic
exercise programs, inhibit functional skill performance, and reduce the likelihood of achieving favorable outcomes
from rehabilitation.

The rehabilitation interventions also might affect the medical condition adversely, causing an exacerbation of the
disease or necessitating an adjustment in the treatment program. Patients who are treated in a stroke unit have
better outcomes at discharge than do patients who are not.[10]

S gical Op ion
Tendon release can be performed in cases of severe spasticity or contractures.

Carotid endarterectomy can be carried out in patients with stenosis of 70% or greater.

There is no longer any clear indication for carotid artery bypass to prevent stroke or in patients who have had a
TIA. No benefit has been demonstrated from the surgery.

Although there have been reports of successful cases involving surgical bypass or endarterectomy involving the
posterior circulation, these procedures remain largely experimental.

Con l a ion in S oke

Consultations with neurologists and physiatrists are important aspects of treatment in patients who have suffered
stroke.

Consultations with psychologists are also essential. Psychosocial issues obviously are very important in cases of
stroke. Numerous studies have reported on the influence of the psychological adjustment and coping mechanisms
of the patient, as well as those of his/her spouse and other family members, in determining the patient s outcome.

O he T ea men Op ion
Biofeedback attempts to modify autonomic functions, pain, and motor disturbances through acquired volitional
control, using auditory, visual, and sensory clues.[11]

Functional electrical stimulation commonly is employed in the UEs and LEs to improve strength, encourage and
augment early active ROM, assist in the management of dependent peripheral edema through forceful isotonic
muscle contraction, and establish early proprioceptive joint sense in the sensory-compromised patient.[12]

Rehabilitation programs are offered in different settings, such as acute inpatient rehabilitation units, subacute
inpatient rehabilitation units, home care environments, and outpatient centers. The acute rehabilitation setting is
appropriate for patients who meet the admission criteria and are able to tolerate 3 hours or more of active therapy
per day.

An acute rehabilitation setting is preferred if the patient requires close monitoring of his/her medical status by
medical and nursing professionals. If the patient's medical status is stable but the patient is unable to tolerate
more than 1 hour of therapy a day, a subacute rehabilitation or skilled nursing setting is more appropriate. Patients
who are independent or require only minimal assistance in self-care tasks and mobility are suited for outpatient
therapy or a home care program.

Rehabili a ion ni

Medical stability traditionally has been required for admission of a patient to a specialized rehabilitation unit;
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h ee,h i a i c ea i g a e a fe i g a ie f ac e a d ehabi i a i i a ea ie age ,
fe he he a ie i ha e e ed edica be .

Thi ac ice ha f ced ehabi i a i ce e e a d hei e ce ca e f he e ec e ca e

a d ide c e edica a d i g i i g. L ca i i i a efe a a e a d ac ice a
de e i e he i i g f a fe , b if ea ie a fe ehabi i a i ca be acc i hed afe , a ie ca e
a be e ha ced b ea ie ac i e a ici a i f he a ie i he ehabi i a i g a .[13]

P a i g f di cha ge f he i a ie ehabi i a i ga h d begi ad i i . Di cha ge f c i a

a , de i a i f di cha ge, a d e g h f h ia a aec a ab e i a ie ihag d g i .
Di cha ge f c i a a i c a ab e i a ie iha fa ab e g i ,b a i i highe a d he
h ia a i ge i edica a d .

Di cha ge f he h i a f e i h gh f a he e d f ehabi i a i , i h he a i ha a g d
ga e a e he a ie f ei eg a i i he h e a d c i ;h ee,h i a di cha ge i ead
h d be ed a a he e d f he begi i g f a e ife i hich he a ie face he cha e ge f ada i g
diffe e e a d ea i hi a d f ea chi g f e ea i g i ife.

Thi ada a i i e e i gf e e i he fa i a d i h f ie d a ch a ib e a d fi di g a
i e a ea i gf ife i he c i .

Po ac e ehabili a ion

D i g ac e ehabi i a i , a a ie h d be i ed ca ef f e ide ce f ca diac di ea e. The

c a ic fea e f c a a e di ea e a d c ge i e hea fai e a be e e , b f e he a e .
I che ia a be i e .[14]

The c i ica c e ig ifica c e i i g hea di ea e a be b e (eg, e ha e ec ed ge ,

e ce i e fa ig e, e ha g , e a cha ge ). The e ca diac c ica i ca be ea ed cce f a dae
c ai dica i ehabi i a i . The a ie h d de g a ia e ca diac i e iga i ih
e ec ca di g a h , H e i i g, a d ech ca di g a h a d a h d ecei e i a he a .

Ea i i ia i f he a ie i de i ab e. Begi i g ehabi i a i ea i i i e ec da c ica i , ch

a c ac e a d dec di i i g, a d he i a e he a ie . Whe he ei e e he a a a
i de e de a iab e i e i aef ci a ec e i .[15]

E a ai f e gic i ai e h d be ade e ea ed d i g he c e f he ehabi i a i ga .

Idea , e a a i h d be ade ee i he ea ha e f ehabi i a i a i i g f he ec e
ce a d g ide he he a e ic i e e i . A c ea eed f c i ed edica di ec i i e ide i
a ie h ha e ai ed e .

The e f he c i icia i c de i i f edica ca e. Ma a ie ha e g i g a cia ed edica

be ha e i e a ia e i i g a d he a . The c i icia ac a a edica c e , ffe i g
ea ab e g ica i a ie a d fa i , a g i h g ida ce i ed c i f e i fac a d
g i g edica ca e. The c i icia a gi e eade hi he ea a d a i i de e i g ea e
c a d e i g ea e e ec a i .

The i e be ha a a ie ca ha e f i g e e i e he ac i e a ici a i f a ea f
fe i a . The ea e ac i i ie f he ea e be be c di a ed ha de ai ed e a a i ae
ha ed a d ag ee e ade ega di g g a a d ea e i e e i .

Each f he fe i a he a i he ea h d be edgeab e ab he a ia e i e e i
i hi hi /he di ci i ef ea i g he di abi i ie f a ie f i g e. The i e e i h d be di ec ed
a achie i g ecific he a e ic g a , hich a be f he h e (f e a e, ee g a ) ge e
(f i a ce, g a be eached b di cha ge). Ha i g achie ed h e g a , he a ie e he e
ha e f ehabi i a i i di cha ged h e c i e ea e a a a ie .

Rehabi i a i e ie af ci a a ach. Whe i ai e ca be a e ed, e e eff h d be ade

a i a ie i c e a i g f defici a d ada i g a e a i e eh d ha he ca achie e i a

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functional independence.

Home Ca e in S oke
A study by Young and Forster found home care to be cheaper than day hospital services ( 385 vs 620
[approximately $546 vs $880]).[16]

Outcome measurements have indicated a modest advantage in favor of home care.

No difference in outcome was found between home care and hospital-based rehabilitation following acute care.

Hospital-based services are 27% more expensive than home care services.

Geriatric ward patients are 2.4 times less likely to die or to become institutionalized by 6 months if placed in day
hospital service.

Stroke unit patients demonstrate superior ADL performance at 6 months with home care (2.6 times more
expensive) than they do with outpatient therapy.

General medical ward patients had similar outcomes, although outpatient services cost 56% of home care.

Home ca e i k

Risks for suboptimal home care (72.6% prediction/validation rate) include the following:

A depressed caregiver
Inadequate knowledge of how to care for a family member following a stroke
A dysfunctional family

Ca diac P eca ion

The rehabilitation management of patients with identified cardiac complications should include formal clinical
monitoring of pulse and blood pressure during physical activities. Brief electrocardiac monitoring during exercise
can add more specific information.

Note that in deconditioned patients, the resting heart rate may be high, and, in an elderly patient, the estimated
limit for heart rate based on 50% above resting may be too high. For patients on beta blockers, a reasonable limit
might be a heart rate of around 20 beats above the resting level.

A useful set of cardiac precautions in patients undergoing rehabilitation was developed by Fletcher and colleagues.
Activity should be terminated if any of the following symptoms develop:

New onset of cardiopulmonary symptoms

Heart rate decreases to less than 20% of baseline
Heart rate increases to greater than 50% of baseline
Systolic BP increases to 240 mm Hg
Systolic BP decreases 30 mm Hg from baseline or to less than 90 mm Hg
Diastolic shortening fraction increases to 120 mm Hg

Complica ion D ing Rehabili a ion

Medical complications frequently occur during the postacute phase of rehabilitation, affecting up to 60% of patients
(and up to 94% of patients with severe lesions).

Common medical complications include the following:

Pulmonary aspiration, pneumonia - 40%

Urinary tract infection - 40%
Depression - 30%
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M c lo kele al pain, efl mpa he ic d oph - 30%
Fall - 25%
Maln i ion - 16%
Veno h omboemboli m - 6%
Pe e lce - 3%

The mean of ea ing dep e ion in pa ien follo ing oke emain nce ain. One d fo nd e idence ha
pha maco he ap can ed ce dep e i e mp om in he e pa ien b ha i can al o inc ea e ad e e
e en .[17] The epo fo nd no e idence ha p cho he ap ed ce dep e ion.

Common ne ologic complica ion incl de he follo ing:

To ic o me abolic encephalopa h - 10%

S oke p og e ion - 5%
Sei e - 4%

In i chemic oke pa ien ho e e follo ed o e he co e of 2-4 ea , ei e de eloped in 6-9% of

pa ien . Sei e de eloped in 26% of pa ien i h co ical le ion and in 2% of pa ien i h bco ical
le ion . Ri k fac o incl de he follo ing:

Loba hemo hage (ac e)

Co ical le ion (ch onic)
Pe i en pa e i (50%)

O he i k fac o incl de he follo ing:

Lang age f nc ion defici , d a h ia

Vi al field defec (20%), hemianopia
Po e and balance defici
Sen o , cogni i e, and pe cep al f nc ion defici
Bo el and bladde incon inence
Decondi ioning
Conge i e hea fail e
H pe en ion
DM
D pha ia
Spa ici
Con ac e
He e o opic calcifica ion

P ogno i in S oke
Significan imp o emen in UE f nc ion all i een onl in he fi 3 mon h po oke. If no e n of mo o
f nc ion i no ed af e mo e han 6 mon h , p ogno i fo ef l f nc ion i nfa o able. If no e n of ol n a
mo o f nc ion i no ed af e mo e han 1 eek, i i nlikel ha f ll e of he affec ed UE ill e n.

Poo p ogno ic indica o incl de he follo ing:

P op iocep i e facili a ion ( apping) e pon e fo mo e han 9 da

T ac ion e pon e ( ho lde fle o /add c o ) in mo e han 13 da
P olonged flaccid pe iod
On e of mo ion a longe han 2-4 eek
Se e e p o imal pa ici
Ab ence of ol n a hand mo emen fo mo e han 4-6 eek

S oke ehabili a ion o come

P edic o of o come incl de he follo ing:

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T pe, distribution, pattern, and severit of ph sical impairment[18]

Cognitive, language, and communication abilities
Number, t pes, and severit of comorbid conditions
level of motivation or determination
Coping abilit and coping st le
Nature and degree of famil and social supports
T pe and qualit of the specific training and adaptation program provided

Remarkable recoveries have been reported in 3-6 ears. (Patients have returned to work 3 ears poststroke).

Starting rehabilitation earl correlates with better outcome but ma be confounded b case severit . (See the
graphs below.) However, stroke rehabilitation improves functional abilit even in patients who are elderl or
medicall ill, as well as in those who have severe neurologic/functional deficits. Significant gains that are achieved
are not attributable onl to spontaneous recover .

The bar graphs show the percentages of patients w ith stroke w ho demonstrated different outcomes on the modified Rankin Scale of
global disabilit . These results w ere recorded 3 months follow ing treatment of patients w ith tissue plasminogen activator (tPA) or
placebo, in the National Institutes of Neurological Disorders and Stroke tPA trials 1 and 2. Rankin 0 = no s mptoms; 1 = no significant
disabilit , despite s mptoms (able to perform all usual duties and activities); 2 = slight disabilit (unable to perform all previous activities
but able to look after ow n affairs w ithout assistance); 3 = moderate disabilit (requires some help, but able to w alk w ithout assistance);
4 = moderatel severe disabilit (unable to w alk w ithout assistance and unable to attend to ow n bodil needs w ithout assistance); 5 =
severe disabilit (bedridden, incontinent, and requires constant nursing care and attention); 6 = dead. Image courtes of UCLA Stroke
Center.

Of patients who survive stroke b more than 30 da s, 10% demonstrate complete spontaneous recover , 10%
show no benefit from an treatment, and 80% ma benefit from treatment. Stroke survivors who do not undergo
rehabilitation are more likel to be institutionali ed.

Eight -five percent of patients went home after 3 months of participation in a stroke rehabilitation program. After 43
da s, 80% of patients returned home, 85% were ambulator , and 50-62% were independent in performance of
ADL. Functional state improved in the stroke unit from 6-52 weeks.

Patients in outpatient and nonoutpatient therap groups showed statistical improvement between stroke onset,
discharge to home, and 1- ear follow-up. The outpatient therap group required a longer rehabilitation sta , was
more impaired at onset, and did not perform as well as the nonoutpatient group. The outpatient therap group was
associated with complete UE/LE hemiplegia, unilateral neglect, impaired proprioception, and urinar incontinence.

Sphincter function, level of neurologic impairment, and capacit to perform ADL related to outcome are assessed,
but these measures are not useful to anticipate the outcome of each patient.

Patients unable to walk 3 months poststroke received therap up to 2 ears after the stroke. Sevent -four percent
of patients walked without assistance. Sevent -nine percent of patients had a modified Barthel score below 70.

Rehabilitation should include therap directed at specific training of skills and functional training. Therap should
be given with sufficient intensit to promote skill acquisition.

A population-based stud b Dhamoon et al suggests that within a group of patients who have suffered ischemic
stroke, there will be an annual decline for up to 5 ears in the proportion of patients who are functionall
independent that is unrelated to recurrent stroke and other risk factors.[19]

In the stud , 525 patients aged 40 ears or older (mean age, 68.6 ) with incident ischemic stroke were

emedicine.medscape.com/article/324386-overview#showall 11/14
1/9/12 Motor Recover In Stroke
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Contributor Information and Disclosures

A
Auri Bruno-Petrina, MD, PhD C T ,P M M C ,NV

A B -P , MD, P D :A A P
M R ,C A P M R ,C
P S B C , I S P R M

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Milton J Klein, DO, MBA C P ,H V H S -S H O
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emedicine.medscape.com/article/324386-overview#showall 12/14
1/9/12 Motor Recover In Stroke
E al a ing Ph ician , Ame ican Academ of Medical Ac p nc e, Ame ican Academ of O eopa h ,
Ame ican Academ of Ph ical Medicine and Rehabili a ion, Ame ican Medical A ocia ion, Ame ican
O eopa hic A ocia ion, Ame ican O eopa hic College of Ph ical Medicine and Rehabili a ion, Ame ican
Pain Socie , and Penn l ania Medical Socie

Di clo e: No hing o di clo e.

Francisco Tala era, PharmD, PhD Adj nc A i an P ofe o , Uni e i of Neb a ka Medical Cen e
College of Pha mac ; Edi o -in-Chief, Med cape D g Refe ence

Di clo e: Med cape Sala Emplo men

Richard Salcido, MD Chai man, E dman P ofe o of Rehabili a ion, Depa men of Ph ical Medicine and
Rehabili a ion, Uni e i of Penn l ania School of Medicine

Richa d Salcido, MD i a membe of he follo ing medical ocie ie : Ame ican Academ of Pain Medicine,
Ame ican Academ of Ph ical Medicine and Rehabili a ion, Ame ican College of Ph ician E ec i e ,
Ame ican Medical A ocia ion, and Ame ican Pa aplegia Socie

Di clo e: No hing o di clo e.

Chief Edi o
Denise I Campagnolo, MD, MS Di ec o of M l iple Scle o i Clinical Re ea ch and S aff Ph ia i , Ba o
Ne olog Clinic , S Jo eph' Ho pi al and Medical Cen e ; In e iga o fo Ba o Ne olog Clinic ; Di ec o ,
NARCOMS P ojec fo Con o i m of MS Cen e

Deni e I Campagnolo, MD, MS i a membe of he follo ing medical ocie ie : Alpha Omega Alpha, Ame ican
A ocia ion of Ne om c la and Elec odiagno ic Medicine, Ame ican Pa aplegia Socie , A ocia ion of
Academic Ph ia i , and Con o i m of M l iple Scle o i Cen e

Di clo e: Te a Ne o cience Hono a ia Speaking and eaching; Se ono-Pfi e Hono a ia Speaking and
eaching; Gen me Co po a ion G an / e ea ch f nd in e iga o ; Biogen Idec G an / e ea ch f nd
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