Jean Marie’s grandmother recently had a stroke and is currently receiving rehabilitation. After seeing her treatment sessions, she realized there are still so many myths regarding the treatment of this patient population. The literature abounds in the area of stroke rehabilitation. We would like to share with you some of the more recent findings that are available to support interventions for stroke rehabilitation and arm your treatment arsenal with a few creative ideas.

Many therapists and assistants have been taught that strength training is inappropriate for stroke patients due to spasticity and that treatment should focus more so on function. Hachisuka showed that hemiplegic patients who had undergone traditional rehabilitation, which did not include muscle strengthening, had a considerable amount of muscle atrophy especially in the type II fibers¹. The newer literature is extremely supportive of utilizing strength training to attain significant functional results with patients.  To reinforce this, Dickstein² looked at repetitive range of motion and found that muscles had no training effect at all with this type of activity in someone who has had a stroke. Therefore the overload principle is necessary to achieve results and there are numerous studies that support intensive strength training. Weiss³ did a twelve-week intensive training program with patients one-year status post stroke. The patients performed a 70% one-repetition maximum program twice a week, which resulted in a 68% increase in strength. This had a concomitant effect on transfers to standing, balance and motor performance tasks, all which improved. Kwallek⁴ found similar results with intense strength training of the lower extremity.  Two studies Salmela⁵ and Sharp⁶ found that progressive resistive exercise (PRE) is excellent for reducing impairment and disability in stroke survivors. They also noted that PRE does not increase spasticity at all. A resourceful method was developed by Dean⁷, where patients three months status post stroke performed circuit training for strengthening and functional tasks three times a week for four weeks. At the conclusion of the study, patients had significant improvements in strength; walking speed, sit to stand transfers and endurance. At the two-month follow-up, the experimental group continued to show improvements in function.

Strength training has superb results with patients but lest we forget strategies also need to focus on increasing the speed of contraction⁸ of muscle groups. For those patients who are so weak that attaining a muscle contraction is a challenge, Colduck⁹ found a method that is helpful in eliciting increased contractions in weak muscles. By performing a passive stretch followed-by an eccentric contraction which is immediately followed-by a concentric contraction, patients are able to obtain a contraction. Functional electrical stimulation (FES) has also been used for increasing strength in extremely weak muscles. Shoulder subluxation is a problem experienced by many stroke survivors. Faghri¹⁰ used functional electrical stimulation to work on subluxation of the shoulder. He published a study showing significant improvements. In 1997, he published a similar study with a larger population, which showed the same results. Francisco¹¹ researched electromyographic neuromuscular stimulation (EMS), an intervention similar to FES. He found that the group receiving EMS had much better scores on both the Functional Independence Measure (FIM) and Fugl Meyer tests. An electrical stimulation mesh glove was found to increase strength in the hand by Dimitrijevic¹² in patients that were six months status post stroke. Patients received electrical stimulation daily for 2-10 months, which resulted in improved wrist extension and decreased biceps spasticity. Chawla¹³, Chae¹⁴ Wong¹⁵ and Cauraugh¹⁶, all showed that patients with hemiplegia receiving FES for strength training had better results than the control group who received traditional rehabilitation. Therefore the addition of FES to a therapeutic program for stroke patients can help maximize their results. FES should be set at strengthening levels in an attempt to achieve a maximal contraction of each of the appropriate muscle groups. 

In addition, the upper extremity has been shown in several studies to be positively affected by constraint induced movement therapy also known as forced use therapy. The most well known of these is Kunkel’s¹⁷ study that showed constraint induced movement therapy, restraining the unaffected upper extremity for fourteen days with 6 hours of daily training to the involved extremity resulted in improved function.  However, for patients to receive this therapy they must be able to extend at least 20 degrees at the wrist and 10 degrees at the metacarpal and PIP joints of the involved extremity. 

Another area that is extremely important is sitting balance. Morgan¹⁸ looked at the relationship between sitting balance and mobility outcomes in stroke patients. He found that the lack of sitting balance of a patient 24 hours after a stroke correlated with dependent gait at six weeks post stroke. Additionally, Tanaka¹⁹ found that the peak torque of trunk flexion and extension in stroke patients was significantly less than healthy controls. Therefore it is important to address strengthening of the trunk musculature in the treatment program to maximize functional outcomes and safety. 

Gait training strategies are well supported in the literature. On a daily basis, therapists instruct patients to initiate gait with one particular limb. Hesse²⁰ found that when stroke patients initiated gait with the unaffected leg, the swing phase and step length was shorter and the center of pressure displayed a marked medio-lateral sway. However, when patients initiated gait with their affected leg, the movement pattern of the center of pressure and center of mass was comparable to normal (non-stroke) subjects. This will in turn affect gait velocity and safety. Another gait training method, treadmill training, has been shown to be efficacious for stroke patients. Visintin²¹, Hesse^{22, 23} and Liston²⁴ all show that treadmill training with a percentage of the body weight supported and subsequently decreased resulted in better walking abilities than conventional gait training while the patients were bearing full weight. A creative intervention was done by Chaudhuri²⁵, which found that lifts supplied to the shoe on the stronger limb induced a body weight shift towards the paretic limb and resulted in improved symmetry and postural control. Finally a suggestion to help patients with decreased tone is detailed by Brown²⁶. He looked at vertical versus horizontal pedaling and found that vertical pedaling tend to exacerbate tone, while horizontal pedaling tends to minimize overall tone. If the therapy goal is to minimize overall tone, therapists should have patients use a recumbent bike so pedaling is more horizontal. If the goal of therapy is to increase muscle force generation then pedaling must be practiced vertically on a stationary bike.  

Is it fact or fiction that patients cannot benefit from therapy or improve after six months from the stroke? Werner²⁷ poignantly brings home this point. He looked at patients who were one-year status post stroke with an average of 2.9 years post. Patients in the experimental group received one hour of physical therapy and occupational therapy four times a week for twelve weeks and had significant gains compared to the control group who actually lost ground in the nine-month follow-up period. Intensive rehabilitation can be provided long after the initial insult with good results. The six-month time period is artificial and should not be heeded. Another interesting study by Andersen²⁸ looked at providing an after care program to stroke survivors who were discharged to home. Patients in the experimental group received instruction in the home by a therapist who then helped them with functional tasks and problem solving for one hour. The average number of visits was three but varied from one to eight. The re-admission rate six months status post stroke was significantly less in the experimental group. Readmission is common among disabled stroke survivors. Follow-up intervention after discharge seems to be a way of preventing readmission, especially for patients with long inpatient rehabilitation stays. 

After seeing the rehabilitation of a close relative, it is obvious that physical therapists’ energy and commitment to patient care abounds. Our hope is that this update on the research will help to justify what is currently being done as well as encourage modification to standard programs. 

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2. Dickstein R, et al.  “Repetitive Practice of a Single Joint Movement for Enhancing Elbow Function in Hemiparetic Patients.” Perceptual and Motor Skills (1997);85:771-785.
3. Weiss A, Suzuki T, Bean J, Fielding RA. “High Intensity Strength Training Improves Strength and Functional Performance After Stroke.” Am J Phys Med Rehabil, (2000);79(4):369-376.
4. Kwakkel G et al.  “Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomized trial.”  The Lancet, (1999); 354: 191-196.
5. Salmela-Teixeira L, Olney S, Nadeau S, Brouwer B.  “Muscle Strengthening and Physical Conditioning to Reduce Impairment and Disability in Chronic Stroke Survivors.”  Archives of Physical Medicine and Rehabilitation, (1999); 80: 1211-1218.
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28. Andersen HE, Schultz-Larsen K, Kreiner S, Forchhammer BH, Eriksen K, Brown A. “Can readmission after stroke be prevented? Results of a randomized clinical study” Stroke, (2000);31:1038-1045.