Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514228
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Physiatrists play a vital role in post-stroke dysphagia management not only by providing guidance on the risks, benefits, and efficacy of various treatment options but also as advocates for patients' independence and qua...Physiatrists play a vital role in post-stroke dysphagia management not only by providing guidance on the risks, benefits, and efficacy of various treatment options but also as advocates for patients' independence and quality of life. While swallow study results are often discussed broadly by acute stroke clinicians as "pass/fail" findings, physiatrists need a more nuanced working knowledge of dysphagia diagnosis and treatment that encompasses swallow pathophysiology, targeted treatment strategies, and prognosis for recovery. To that end, this review summarizes current clinical practice guidelines on dysphagia, nutrition and oral care, risks and benefits of differing enteral access routes, prognostic factors, and approaches to rehabilitation.
Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514227
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Poststroke aphasia, which impacts expressive and receptive communication, can have detrimental effects on the psychosocial well-being and the quality of life of those affected. Aphasia recovery is multidimensional and ca...Poststroke aphasia, which impacts expressive and receptive communication, can have detrimental effects on the psychosocial well-being and the quality of life of those affected. Aphasia recovery is multidimensional and can be influenced by several baseline, stroke-related, and treatment-related factors, including preexisting cerebrovascular conditions, stroke size and location, and amount of therapy received. Importantly, aphasia recovery can continue for many years after aphasia onset. Behavioral speech and language therapy with a speech-language pathologist is the most common form of aphasia therapy. In this review, the authors also discuss augmentative treatment methodologies, collaborative goal setting frameworks, and recommendations for future research.
Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514226
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Botulinum toxin (BonT) is the mainstream treatment option for post-stroke spasticity. BoNT therapy may not be adequate in those with severe spasticity. There are a number of emerging treatment options for spasticity mana...Botulinum toxin (BonT) is the mainstream treatment option for post-stroke spasticity. BoNT therapy may not be adequate in those with severe spasticity. There are a number of emerging treatment options for spasticity management. In this paper, we focus on innovative and revived treatment options that can be alternative or complementary to BoNT therapy, including phenol neurolysis, cryoneurolysis, and extracorporeal shock wave therapy.
Rajashekar D, Boyer A, Larkin-Kaiser KA
… +1 more, Dukelow SP
Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514225
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Robotic technology and virtual reality (VR) have been widely studied technologies in stroke rehabilitation over the last few decades. Both technologies have typically been considered as ways to enhance recovery through p...Robotic technology and virtual reality (VR) have been widely studied technologies in stroke rehabilitation over the last few decades. Both technologies have typically been considered as ways to enhance recovery through promoting intensive, repetitive, and engaging therapies. In this review, we present the current evidence from interventional clinical trials that employ either robotics, VR, or a combination of both modalities to facilitate post-stroke recovery. Broadly speaking, both technologies have demonstrated some success in improving post-stroke outcomes and complementing conventional therapy. However, more high-quality, randomized, multicenter trials are required to confirm our current understanding of their role in precision stroke recovery.
Osman H, Siu R, Makowski NS
… +2 more, Knutson JS, Cunningham DA
Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514224
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Neural stimulation technology aids stroke survivors in regaining lost motor functions. This article explores its applications in upper and lower limb stroke rehabilitation. The authors review various methods to target th...Neural stimulation technology aids stroke survivors in regaining lost motor functions. This article explores its applications in upper and lower limb stroke rehabilitation. The authors review various methods to target the corticomotor system, including transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and vagus nerve stimulation. In addition, the authors review the use of peripheral neuromuscular electrical stimulation for therapeutic and assistive purposes, including transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation, and functional electrical stimulation. For each, the authors examine the potential benefits, limitations, safety considerations, and FDA status.
Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514223
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Stroke remains a top contributor to long-term disability in the United States and substantially limits a person's physical activity. Decreased cardiovascular capacity is a major contributing factor to activity limitation...Stroke remains a top contributor to long-term disability in the United States and substantially limits a person's physical activity. Decreased cardiovascular capacity is a major contributing factor to activity limitations and is a significant health concern. Addressing the cardiovascular capacity of stroke survivors as part of poststroke management results in significant improvements in their endurance, functional recovery, and medical outcomes such as all-cause rehospitalization and mortality. Incorporation of a structured approach similar to the cardiac rehabilitation program, including aerobic exercise and risk factor education, can lead to improved cardiovascular function, health benefits, and quality of life in stroke survivors.
Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514222
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More intense, earlier exercise in rehabilitation results in improved motor outcomes following stroke. Timing and intensity of therapy delivery vary from study to study. For more intensive therapies, there are practical c...More intense, earlier exercise in rehabilitation results in improved motor outcomes following stroke. Timing and intensity of therapy delivery vary from study to study. For more intensive therapies, there are practical challenges in implementation. However, there are also opportunities for high intensity treatment through innovative approaches and new technologies. Timing of rehabilitation is important. As time post stroke increases, the dosage of therapy required to improve motor recovery outcomes increases. Very early rehabilitation may improve motor outcomes but should be delayed for at least 24 hours post stroke.
Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514221
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Remote ischemic conditioning (RIC) is a therapeutic strategy to protect a vital organ like the brain from ischemic injury through brief and repeat cycles of ischemia and reperfusion in remote body parts such as arm or le...Remote ischemic conditioning (RIC) is a therapeutic strategy to protect a vital organ like the brain from ischemic injury through brief and repeat cycles of ischemia and reperfusion in remote body parts such as arm or leg. RIC has been applied in different aspects of the stroke field and has shown promise. This narrative review will provide an overview of how to implement RIC in stroke patients, summarize the clinical evidence of RIC on stroke recovery, and discuss unresolved questions and future study directions.
Cramer SC, Young BM, Schwarz A
… +2 more, Chang TY, Su M
Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514220
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Stroke remains a major cause of disability. Intensive rehabilitation therapy can improve outcomes, but most patients receive limited doses. Telehealth methods can overcome obstacles to delivering intensive therapy and th...Stroke remains a major cause of disability. Intensive rehabilitation therapy can improve outcomes, but most patients receive limited doses. Telehealth methods can overcome obstacles to delivering intensive therapy and thereby address this unmet need. A specific example is reviewed in detail, focused on a telerehabilitation system that targets upper extremity motor deficits after stroke. Strengths of this system include provision of daily therapy associated with very high patient compliance, safety and feasibility in the inpatient or home setting, comparable efficacy to dose-matched therapy provided in-clinic, and a holistic approach that includes assessment, education, prevention, and activity-based therapy.
Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514219
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Stroke outcomes are influenced by factors such as education, lifestyle, and access to care, which determine the extent of functional recovery. Disparities in stroke rehabilitation research have traditionally included age...Stroke outcomes are influenced by factors such as education, lifestyle, and access to care, which determine the extent of functional recovery. Disparities in stroke rehabilitation research have traditionally included age, race/ethnicity, and sex, but other areas make up a gap in the literature. This article conducted a literature review of original research articles published between 2008 and 2022. The article also expands on research that highlights stroke disparities in risk factors, rehabilitative stroke care, language barriers, outcomes for stroke survivors, and interventions focused on rehabilitative stroke disparities.
Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514218
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Sensorimotor impairments are common after stroke requiring stroke survivors to relearn lost motor skills or acquire new ones in order to engage in daily activities. Thus, motor skill learning is a cornerstone of stroke r...Sensorimotor impairments are common after stroke requiring stroke survivors to relearn lost motor skills or acquire new ones in order to engage in daily activities. Thus, motor skill learning is a cornerstone of stroke rehabilitation. This article provides an overview of motor control and learning theories that inform stroke rehabilitation interventions, discusses principles of neuroplasticity, and provides a summary of practice conditions and techniques that can be used to augment motor learning and neuroplasticity in stroke rehabilitation.
Ackerley S, Smith MC, Jordan H
… +1 more, Stinear CM
Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514217
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Predicting motor outcomes after stroke based on clinical judgment alone is often inaccurate and can lead to inefficient and inequitable allocation of rehabilitation resources. Prediction tools are being developed so that...Predicting motor outcomes after stroke based on clinical judgment alone is often inaccurate and can lead to inefficient and inequitable allocation of rehabilitation resources. Prediction tools are being developed so that clinicians can make evidence-based, accurate, and reproducible prognoses for individual patients. Biomarkers of corticospinal tract structure and function can improve prediction tool performance, particularly for patients with initially moderate to severe motor impairment. Being able to make accurate predictions for individual patients supports rehabilitation planning and communication with patients and families.
Phys Med Rehabil Clin N Am
· 2024 May · PMID 38514216
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Stroke remains a leading cause of disability. Motor recovery requires the interaction of top-down and bottom-up mechanisms, which reinforce each other. Injury to the brain initiates a biphasic neuroimmune process, which...Stroke remains a leading cause of disability. Motor recovery requires the interaction of top-down and bottom-up mechanisms, which reinforce each other. Injury to the brain initiates a biphasic neuroimmune process, which opens a window for spontaneous recovery during which the brain is particularly sensitive to activity. Physical activity during this sensitive period can lead to rapid recovery by potentiating anti-inflammatory and neuroplastic processes. On the other hand, lack of physical activity can lead to early closure of the sensitive period and downstream changes in muscles, such as sarcopenia, muscle stiffness, and reduced cardiovascular capacity, and blood flow that impede recovery.
Phys Med Rehabil Clin N Am
· 2024 Feb · PMID 37993196
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Behavioral assessment remains the cornerstone of the clinical evaluation of disorders of consciousness (DoC). Because the basic approach to these evaluations has been extensively reviewed elsewhere, this article focuses...Behavioral assessment remains the cornerstone of the clinical evaluation of disorders of consciousness (DoC). Because the basic approach to these evaluations has been extensively reviewed elsewhere, this article focuses on special considerations in the behavioral assessment of patients with a DoC. All therapy disciplines (physical therapy/occupational therapy/speech language pathologist) have a significant role to play and other staff and family members should also be encouraged to share their observations. Finally, the assessment with standardized scales should be supplemented by qualitative behavioral observations as well as, when appropriate, an individualized quantitative behavioral assessment.
Phys Med Rehabil Clin N Am
· 2024 Feb · PMID 37993195
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Acute disorders of consciousness (DOC) are impairments in arousal and awareness that occur within 28 days of an initial injury and can result from a variety of insults. These states range from coma, unresponsive wakefuln...Acute disorders of consciousness (DOC) are impairments in arousal and awareness that occur within 28 days of an initial injury and can result from a variety of insults. These states range from coma, unresponsive wakefulness, covert consciousness, minimal consciousness, to confusional state. It is important to perform thorough, serial examinations with particular emphasis on the level of consciousness, brainstem reflexes, and motor responses. Evaluation of acute DOC includes laboratory tests, imaging, and electrophysiology testing. Prognostication in the acute phase of DOC must be done cautiously, using open, frequent communication with families, and by acknowledging significant multidimensional uncertainty.
Phys Med Rehabil Clin N Am
· 2024 Feb · PMID 37993194
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Rehabilitation of patients with disorders of consciousness (DoC) presents unique challenges requiring comprehensive and specialized care. This article reviews the components, organization, and implementation of an inpati...Rehabilitation of patients with disorders of consciousness (DoC) presents unique challenges requiring comprehensive and specialized care. This article reviews the components, organization, and implementation of an inpatient DoC program under the framework of recent evidence-based practice guidelines and minimum competency recommendations. The evidence and clinical applications of these recommendations are elaborated upon with the goal of offering providers a reference to translate guidelines into clinical practice.
Phys Med Rehabil Clin N Am
· 2024 Feb · PMID 37993193
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There is a clinical need for more accurate diagnosis and prognostication in patients with disorders of consciousness (DoC). There are several neuroimaging modalities that enable detailed, quantitative assessment of struc...There is a clinical need for more accurate diagnosis and prognostication in patients with disorders of consciousness (DoC). There are several neuroimaging modalities that enable detailed, quantitative assessment of structural and functional brain injury, with demonstrated diagnostic and prognostic value. Additionally, longitudinal neuroimaging studies have hinted at quantifiable structural and functional neuroimaging biomarkers of recovery, with potential implications for the management of DoC.
Phys Med Rehabil Clin N Am
· 2024 Feb · PMID 37993192
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Understanding the structural and functional neuroanatomy of core consciousness (ie, wakefulness and awareness) is an asset to clinicians caring for persons with disorders of consciousness. This article provides a primer...Understanding the structural and functional neuroanatomy of core consciousness (ie, wakefulness and awareness) is an asset to clinicians caring for persons with disorders of consciousness. This article provides a primer on the structural and functional neuroanatomy of wakefulness and awareness. The neuroanatomical structures supporting these elements of core consciousness functions are reviewed first, after which brief description of the clinically evaluable relationships between disruption of these structures and disorders of consciousness (ie, brain-behavior relationships) are outlined. Consideration of neuroanatomy at the mesoscale (ie, the mesocircuit hypothesis) as well as in relation to several large-scale neural networks is offered.