Robert TeasellStroke Recovery and Rehabilitation

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Stroke Recovery and RehabilitationRobert Teasell, MD, FRCPC

One of the most exciting areas of stroke research is ourincreasing understanding of the brain’s plasticity andthe ability of rehabilitation to influence neurological

recovery and subsequently impact clinical outcomes.Pomeroy and Tallis1 note, “The recent revolution in ourunderstanding of the nervous system as being soft-wired, ofthe potential for recovery through reorganization and of thecentral role of afferent information is ground for optimism.”

Stroke RecoveryNumerous theories and hypothesis have been forwarded toexplain the neurological recovery seen after an acute stroke.Functional brain imaging has offered an opportunity tovisualize cerebral activation associated with recovery from astroke. Functional MRI, PET, and transcranial magneticstimulation are now being used to demonstrate activationafter stroke associated with specific stimuli or tasks.2

Studies examining recovery of the affected upper extremitywith rehabilitation therapies have shown distinct patterns ofcortical reorganization. The predominate pattern, which cor-relates with therapy-related improvements in upper extremitymovement, involves increases in fMRI activity in the premo-tor cortex and secondary somatosensory cortex contralateralto the affected arm and in the superior posterior regions of thecerebellum bilaterally.3 Stroke patients not only show thisextended activation on the contralateral side, but unlikecontrols they also activate the ipsilateral motor cortex.4 Feydyet al5 were able to demonstrate that the nature of the lesionplayed a role in the development of cortical reorganization;involvement of the primary motor cortex resulted in increasedipsilateral activation, whereas sparing of the primary motorcortex resulted in increased contralateral sensorimotor cortexinvolvement. Cramer et al6 used fMRI to study unilateralstroke patients with chronic hemiplegia that spared regions ofmotor cortex. Activation in stroke-affected hemisphere wasevaluated by stimuli/activities independent of the stroke-affected corticospinal tract. Stroke patients activated surviv-

ing cortical regions with similar frequency as controls,generally with a smaller activation volume. After a chronichemiplegic stroke, surviving motor cortex demonstrated pre-served activation for upper extremity sensorimotor functions.

Functional brain imaging has also been used in aphasicpatients. Not unexpectedly, there is predominance of the lefthemisphere over the right in language functions; however,language recovery depends on the restitution of the speech-relevant network that involves both hemispheres.7

Stroke RehabilitationStroke rehabilitation research has enjoyed a renaissance overthe past decade. A recent review of the stroke rehabilitationliterature discovered 270 randomized controlled trials lookingspecifically at issues that involved rehabilitation of strokepatients through 2001.8 What was most remarkable was thebreathtaking and exponential pace at which randomizedcontrolled trials (RCTs) in stroke rehabilitation are beingundertaken; the results from almost 100 RCTs were publishedfrom 1997 to 2001 alone.

Pettersen et al9 found that after stroke rehabilitation,deterioration occurs as a consequence of concomitant chronicdisabling disorders and recurrent strokes; otherwise, patientstend to remain within their own home with �80% still doingso at 3 years. The tools we have come to rely on, the FIM andBarthel Indices, may underestimate the impact of stroke; newtools like the Stroke Impact Scale, which measure quality oflife, seem to be more inclusive, with the finding that “recov-ered” stroke still had a negative impact on a variety offunctional activities.10

There is now strong evidence when comparing RCTs thatgreater intensity of aphasia therapy results in improvedoutcomes as opposed to less intense therapy, where thereseems to be little or no benefit.11 Cauraugh and Kim12

demonstrated the benefits of coupling different motor recov-ery treatments to improve motor outcomes after stroke.Pewrala et al13 found cutaneous stimulation combined withinpatient rehabilitation in the paretic upper extremity signif-icantly improved motor performance and upper limb sensa-tion. Along similar lines, Werner et al14 found treadmilltraining with partial body weight support accelerated resto-ration of gait ability in chronic nonambulatory stroke patientscompared with treadmill training alone. Combining therapies,greater intensities of therapy, and increasing overall afferentinput as mechanisms of improving after stroke recovery alongwith functional imaging studies demonstrate the brain’splasticity and potential for recovery after stroke.

Early supported discharge, providing interdisciplinary re-habilitation in the home instead of in a hospital, seems tooffer the same benefits as an in-hospital stroke rehabilitationunit, but this concept has only been tested in a less severelydisabled stroke patient population. A systematic review found

The opinions expressed in this editorial are not necessarily those of theeditors or of the American Stroke Association.

Received December 11, 2002; accepted December 11, 2002.From the Department of Physical Medicine and Rehabilitation, St

Joseph’s Health Care London, Parkwood Hospital, Lawson HealthResearch Institute, University of Western Ontario, London, Ontario,Canada.

Correspondence to Robert Teasell, University of Western Ontario,London Health Sciences Center, Physical Medicine and Rehabilitation,339 Windermere Rd, London, Ontario N6A 5A5, Canada. E-mailrobert.teasell@lhsc.on.ca

(Stroke. 2003;34:365-366.)© 2003 American Heart Association, Inc.

Stroke is available at http://www.strokeaha.orgDOI: 10.1161/01.STR.0000054630.33395.E2

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that such an approach could potentially save hospital beds,with a 15% reduction in overall mean costs in that subset.15

A recent Cochrane review16 reported that care pathways instroke units actually resulted in significantly lower patientsatisfaction and quality of life. The authors noted, “There iscurrently insufficient supporting evidence to justify routineimplementation of care pathways for . . . stroke rehabilita-tion.” This was confirmed by Hoenig et al,17 who found thestructure of care (systemic organization, staffing expertise,and technological sophistication) was not associated withbetter functional outcomes, whereas compliance with AH-CPR poststroke rehabilitation guidelines improved thosesame outcomes. This apparent paradox may signify theimportance of using evidence or guidelines to assist rehabil-itation clinicians in individualizing the rehab of stroke pa-tients as opposed to a “one size fits all” approach.

It has long been known that improved social supportimproves outcomes, and although not studied yet in a formalRCT, the evidence that social support improves outcomes hasbeen impressive. Grant et al18 in an RCT examining a socialproblem-solving telephone partnership intervention acquiredbetter problem-solving skills, less depression, greater care-giver preparedness, and significant gains in social functioningand emotional health. The importance of social support incommunity reintegration continues to be an underestimatedfactor.

Despite the explosion of clinical stroke rehabilitationresearch, there remain many important unanswered questions.The next few years promise to be an exciting time in strokerehabilitation research.

References1. Pomeroy V, Tallis R. Neurological rehabilitation: a science struggling to

come of age. Physiother Res Int. 2002;7:76–89.2. Thirumala P, Hier DB, Patel P. Motor recovery after stroke: lessons from

functional brain imaging. Neurol Res. 2002;24:453–458.3. Johansen-Berg H, Dawed H, Guy C, Smith SM, Wade DT, Matthews PM.

Correlation between motor improvements and altered fMRI activityduring rehabilitative therapy. Brain. 2002;125(pt 12):2731–2742.

4. Kato H, Izumiyama M, Koisumi H, Takahashi A, Itoyama Y. Nearinfrared spectroscopic topography as a tool to monitor motor reorgani-zation after hemiparetic stroke: a comparison with functional MRI.Stroke. 2002;33:2032–2036.

5. Feydy A, Carlier R, Roby-Brami A, Bussel B, Caalis F, Pierot L, BurnottY, Maier MA. Longitudinal study of motor recovery after stroke:recruitment and focusing of brain activation. Stroke. 2002;33:1610–1617.

6. Cramer SC, Mark A, Barquist K, Nhan H, Stegbauer KC, Price R, Bell K,Odderson IR, Esselman P, Maravilla KR. Motor cortex activation ispreserved in patients with chronic hemiplegic stroke. Ann Neurol. 2002;52:607–616.

7. Kuest J, Karbe H. Cortical activation studies in aphasia. Curr NeurolNeurosci Rep. 2002;2:511–515.

8. Teasell RW, Doherty T, Speechley M, Foley N, Bhogal SK.Evidence-Based Review of Stroke Rehabilitation. Heart and Stroke Foun-dation of Ontario and Ministry of Health and Long-Term Care of Ontario,2002. Available at http://www.sjhc.london.on.ca/parkwood/ebrsr/ebrsr/htm.

9. Pettersen R, Dahl T, Wyller TB. Prediction of long-term functionaloutcome after stroke rehabilitation. Clin Rehabil. 2002;16:149–159.

10. Lai SM, Studenski S, Duncan PW, Perera S. Persisting consequences ofstroke measured by the Stroke Impact Scale. Stroke. 2002;33:1840–1844.

11. Bhogal S, Teasell R, Speechley M. Intensity of aphasia therapy impact onrecovery. Stroke. In press.

12. Cauraugh JH, Kim S. Two coupled motor recovery protocols are betterthan one: electromyogram-triggered neuromuscular stimulation andbilateral movements. Stroke. 2002;33:1589–1594.

13. Pewrala SH, Pittanen K, Sivenius J, Tarkka IM. Cutaneous electricalstimulation may enhance sensorimotor recovery in chronic stroke. ClinRehabil. 2002;16:705–716.

14. Werner C, Bardeleben A, Mauritz KH, Kirker S, Hesse S. Treadmilltraining with partial body weight support and physiotherapy in strokepatients: a preliminary comparison. Eur J Neurol. 2002;9:639–644.

15. Anderson C, Ni Mhurchn C, Brown PM, Carter K. Stroke rehabilitationservices to accelerate hospital discharge and provide home-based care: anoverview and cost analysis. Pharmacoeconomics. 2002;20:537–552.

16. Kwan J, Sandercock P. In-hospital care pathways for stroke. CochraneDatabase Syst Rev. 2002;CD002924.

17. Hoenig H, Duncan PW, Horner RD, Reker DM, Samsa GP, Dudley TK,Hamilton BB. Structure, process, and outcomes in stroke rehabilitation.Med Care. 2002;40:1036–1047.

18. Grant JS, Elliott TR, Wesaver M, Bartolucci AA, Giger J. Telephoneintervention with family caregivers of stroke survivors after rehabili-tation. Stroke. 2002;33:2060–2065.

KEY WORDS: magnetic resonance imaging; functional � recovery � rehabilitation� reorganization � stroke

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