Post-Stroke Rehabilitation

Understanding Post-Stroke Rehabilitation

Post-stroke rehabilitation is the process of regaining function and independence after a stroke, which is a loss of blood flow to part of the brain from a blocked or burst blood vessel.^[1] Rehabilitation brings together physical, occupational, speech and cognitive therapies and is planned around each person's deficits.^[2]

Common symptoms

Stroke symptoms depend on which part of the brain is injured. Common problems after a stroke include:

• Weakness, stiffness or poor coordination, usually on one side of the body
• Trouble speaking, understanding speech or swallowing
• Problems with memory, attention and planning
• Pain, including a nerve pain syndrome that can appear months after a stroke^[3]
• Low mood or anxiety^[4]

Causes and risk factors

Stroke is either ischemic, from a blocked artery, or hemorrhagic, from bleeding. Long-standing high blood pressure, hardened arteries and clots from an irregular heartbeat are among the common causes.^[1]

Recovery varies with the size and location of the stroke, general health and how soon rehabilitation starts, so timing and intensity of therapy are decided by your medical team.^[2]

How it is diagnosed and treated conventionally

A stroke is diagnosed in hospital with a history, examination and urgent brain imaging, followed by treatment based on its cause.^[1] Rehabilitation then follows through the hospital, inpatient or outpatient rehabilitation centers, and home, using physical, occupational, speech and cognitive therapies, with attention to technology, caregiver support and fall prevention.^{[2, 5]}

Long-term lifestyle changes and treatment of the underlying causes are part of care.^[1] Complementary care should sit beside this plan and never replace it.

Why Post-Stroke Rehabilitation calls for a whole-person approach

Recovery after a stroke involves more than the weak arm or leg. Mood, pain, muscle tone, swallowing, bladder control and general vascular health all affect how much a person can do and how well they take part in therapy.^{[2, 4]}

Supportive care can address some of these, but it works best as one part of a plan led by your physician and rehabilitation therapists.

Mood and emotional health

Post-stroke depression is common, with rates of about 18 to 33 percent in one review, and it is linked to poorer recovery, more cognitive problems and a lower quality of life.^[4] Treatment usually combines medicines, psychosocial care and stroke-focused rehabilitation.^[4]

Muscle tone, pain and movement

Spasticity, a stiffness and tightness of muscles after damage to the brain or spinal cord, harms quality of life and is not always well controlled by standard treatments.^[6] Nerve pain from the stroke itself is a separate problem that can begin months later and is often undertreated.^[3]

Swallowing and bladder control

Swallowing difficulty is common after stroke and affects prognosis and quality of life.^[7] Urinary incontinence affects 40 to 60 percent of people admitted to hospital after a stroke, and about 15 percent still have it after a year.^[8]

Long-term vascular health

Because the causes of stroke usually remain, controlling blood pressure and making lifestyle changes are part of recovery.^[1]

Acupuncture as supportive care in Post-Stroke Rehabilitation

What the research shows

Research suggests acupuncture may help with some stroke-related problems, but the evidence is mixed and often low in quality. A Cochrane review of 31 trials with 2,257 people in the subacute or chronic stages found that acupuncture added to usual care improved daily living, neurological deficit and motor function, but the evidence was low or very low in quality. Two trials against sham acupuncture found no difference in motor function or quality of life. The authors concluded there was not enough evidence to support routine use.^[9] A later meta-analysis of 58 studies found that adding acupuncture to standard care improved dependency and swallowing, though most studies were short and prone to bias.^[10]

Some specific problems have more recent evidence. In a sham-controlled trial of 252 people with post-stroke motor aphasia, 6 weeks of acupuncture alongside language training gave higher language scores than sham, with the gap still present at 6 months after onset.^[11] A trial of 254 people with swallowing difficulty compared acupuncture with swallowing training and found a greater improvement in a swallowing score after 2 weeks, but no difference in daily living ability.^[7]

For post-stroke depression, a network meta-analysis of 62 trials found acupuncture alone or combined with other therapies appeared effective, while a separate network analysis rated the overall evidence as very low.^{[12, 13]} A narrative review found moderate-quality evidence that electroacupuncture with routine care could reduce spasticity and improve motor function after stroke.^[6] For urinary incontinence after stroke, Cochrane found low-quality evidence that acupuncture-based therapy may increase the number of people who regain continence, with insufficient evidence overall.^[8]

How acupuncture may work

How acupuncture may help recovery is not settled. A review of laboratory studies lists effects on new nerve cell growth, blood flow in the injured area, cell survival, brain chemicals and memory-related changes, drawn from basic laboratory studies.^[14] These are proposed mechanisms, not proven explanations.

What treatment involves

Treatment uses fine, sterile, single-use needles, with sessions of about 20 to 40 minutes, and some points can be connected to a mild electrical stimulator. Trials used courses of about 2 to 6 weeks.^{[7, 11]} We reassess after a short course of visits.

In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[15] Tell the practitioner first if you take blood thinners or have a bleeding disorder, a pacemaker or other implanted device, or loss of feeling in a limb that could hide discomfort.

Ayurvedic medicine as supportive care in Post-Stroke Rehabilitation

The Ayurvedic view

In Ayurveda, the paralysis that can follow a stroke is traditionally described as Pakshaghata, regarded as a disorder of Vata, the principle said to govern movement and nerve function. This is a traditional framework, not a biomedical diagnosis.

Therapies that may be used

Care is chosen for the individual and, in tradition, may include:

• Diet and daily routines suited to the person's strength and digestion
• Gentle warm-oil massage of the limbs
• Individually prescribed herbs

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty, and many stroke survivors are frail or medically fragile. They should be considered only after your physician agrees.

What the research shows

The research is limited. In the first randomized trial of its kind, 140 people in India who had an ischemic stroke received Ayurvedic rehabilitation therapy or physiotherapy. The Ayurvedic protocol was not better than physiotherapy for arm recovery. Arm scores at 3 months were higher with physiotherapy, and the difference was no longer significant after adjustment. No major serious adverse events were reported.^[16] A broader review found no evidence for Ayurveda in stroke recovery, though it noted studies of marma massage, and rated the studies of complementary approaches as generally poor in quality.^[17]

Herbal medicine as supportive care in Post-Stroke Rehabilitation

Herbs and formulas that have been studied

Most research on herbs in stroke comes from China and concerns formulas given in hospital. A Cochrane review examined mailuoning, a Chinese preparation given by injection or as an oral liquid in acute ischemic stroke.^[18] Chinese herbal medicine has also been included in studies of combined Chinese and Western care for stroke rehabilitation.^[10]

What the research shows

The evidence is limited. The Cochrane review of mailuoning included 21 trials, most of poor quality. They suggested better neurological scores, but the one better-quality placebo-controlled trial did not, and the authors found insufficient evidence for routine use.^[18] A meta-analysis of 58 studies of combined Chinese and Western care found possible benefit for depression, though its abstract does not separate herbs from other Chinese medicine methods and many studies were short and prone to bias.^[10] Evidence for herbs in recovery from the effects of stroke, as opposed to treatment of an acute stroke, is thinner still.

Safety and herb-drug interactions

Many stroke survivors take blood thinners, antiplatelet drugs, blood pressure medicines or antidepressants, and herbs can interact with them. A systematic review found that dozens of herbs and supplements, including ginkgo and ginger, can affect warfarin and increase bleeding, with some reports of fatal intracranial bleeding.^[19] Never add an herb without your physician knowing.

About one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Tell us if you have liver or kidney disease, or surgery planned.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine describes stroke sequelae in terms of blocked qi and blood and disturbed channels. Researchers instead study blood flow to injured brain areas, nerve cell survival, brain plasticity, muscle tone and mood.^[14]

Ayurveda's Vata imbalance describes loss of movement and sensation. No study has shown that a dosha corresponds to a specific biological process.

How this care fits with your medical care

Stroke needs medical treatment and a rehabilitation team, and our care is supportive only. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care. Do not stop or change prescribed medicines or skip therapy sessions without your prescriber.

We do not diagnose stroke or manage its medical treatment. Please bring your diagnosis, discharge summary or imaging reports, a full list of medicines and supplements, and the contact details of your physician and therapists.

When to seek urgent medical care

A new stroke or a serious complication needs emergency care at once.^[1]

• Sudden face drooping, arm or leg weakness, or trouble speaking or understanding
• Sudden vision loss, severe headache, dizziness or loss of balance
• Choking, coughing with meals, or fever and breathing trouble that may signal aspiration pneumonia
• A swollen, painful or warm calf or leg, or sudden chest pain or shortness of breath
• Thoughts of suicide or self-harm (call or text the 988 Suicide and Crisis Lifeline)

If any of these occur, call 911 or go to the nearest emergency department.