Rehabilitation

Rehabilitation is a goal-directed, time-limited process that helps a person with impairment reach the best achievable physical, cognitive, psychological and social function. It is organised around the ICF framework, which separates impairment (body structure and function), activity limitation, and participation restriction, with personal and environmental factors modifying each.

Care phases

• Acute: begins in the intensive care unit or acute ward. It covers prevention of complications, positioning, early mobilisation and swallow and cognitive screening.
• Subacute: intensive inpatient or day-unit therapy, typically weeks 1 to 12 after stroke, brain injury or spinal cord injury, when spontaneous neurological recovery is steepest.
• Chronic and community: maintenance, vocational and social reintegration, and management of late complications.

Conditions served include stroke, traumatic brain injury, spinal cord injury, peripheral nerve injury, amputation, fractures and joint replacement, cardiac and pulmonary disease, cancer, critical illness weakness, burns, and paediatric and neurodegenerative disorders.

Principles with the strongest support

• Organised multidisciplinary care in a dedicated unit reduces death and dependency after stroke.
• Recovery depends on dose. Practice must be task-specific, repetitive and progressively challenging.
• Neuroplastic change is greatest in the first 3 months, but gains continue beyond a year with sustained training.
• Very early, high-intensity mobilisation within the first 24 hours of stroke worsens outcome. Short, frequent sessions starting at 24 to 48 hours are preferred.
• Shared goal-setting with the patient and family improves engagement and adherence.

Outcome measures used across disciplines

• Function: Barthel Index, Functional Independence Measure, modified Rankin Scale.
• Mobility and balance: 10 metre walk test, 6 minute walk test, Berg Balance Scale, Timed Up and Go.
• Motor: Fugl-Meyer assessment, Action Research Arm Test, Medical Research Council grading.
• Spasticity: modified Ashworth and Tardieu scales.
• Cognition and mood: Montreal Cognitive Assessment, PHQ-9.

Problems that rehabilitation targets, and how they present

• Weakness and loss of dexterity: pattern depends on the lesion, with pyramidal weakness in the upper limb extensors and lower limb flexors in stroke.
• Spasticity: velocity-dependent resistance, clonus, and posturing such as flexed elbow, pronated forearm, clenched fist, equinovarus foot. It may develop from weeks to months after injury and leads to contracture if untreated.
• Dysphagia: coughing with meals, wet voice and recurrent chest infection. Silent aspiration occurs in a substantial minority.
• Communication and cognition: aphasia, dysarthria, neglect, apraxia, executive dysfunction, memory loss.
• Pain: hemiplegic shoulder pain (up to 30 to 40% after stroke) from subluxation, capsulitis or rotator cuff injury, central post-stroke pain, and complex regional pain syndrome.
• Bladder and bowel: retention, urgency, incontinence, constipation, and impaction.
• Mood and fatigue: depression in about one third, anxiety, apathy, and disabling fatigue.
• Secondary complications: pressure injury, venous thromboembolism, osteoporosis, falls, heterotopic ossification, deconditioning, sleep apnoea, and shoulder-hand syndrome.

Red flags during rehabilitation

• New or worsening neurological deficit, indicating recurrent stroke, hydrocephalus or post-traumatic syrinx.
• Unilateral leg swelling, pleuritic pain or hypoxia.
• Paroxysmal hypertension, headache and sweating above the lesion in cord injury at T6 or above (autonomic dysreflexia).
• Fever with aspiration, urinary sepsis or pressure injury infection.
• Unexplained pain or loss of range at a joint, which may indicate heterotopic ossification or occult fracture.
• Suicidal ideation.

Assessment is multidimensional and repeated at set intervals.

Core evaluation

• Neurological examination with documented strength, tone, sensation, coordination, balance, gait and cognition.
• Bedside swallow screen, followed by videofluoroscopy or fibreoptic endoscopic evaluation of swallowing if aspiration is suspected.
• Cognitive screening and formal neuropsychological testing when return to work or driving is considered.
• Depression screening with PHQ-9 at baseline and during follow-up.
• Functional assessment of transfers, activities of daily living and home environment by occupational therapy.
• Nutrition screen and weight trajectory.

Targeted investigations

• Urodynamics and bladder scan for post-void residual, and renal tract ultrasound in neurogenic bladder.
• Bone density scan and vitamin D level in immobilised or paralysed patients.
• Duplex ultrasound for suspected deep vein thrombosis.
• Electrodiagnostic testing for peripheral nerve injury and for tracking reinnervation.
• Gait analysis and dynamic EMG before surgical planning for spastic gait.
• Echocardiography and exercise testing before cardiac rehabilitation, and spirometry with a 6 minute walk test before pulmonary rehabilitation.

Prognostication guides goal-setting

• After stroke, shoulder abduction and finger extension scores within 72 hours predict upper limb recovery. Retained finger extension by 4 weeks favours useful hand function.
• Sitting balance by 1 week and leg strength predict walking.
• In spinal cord injury, ASIA grade and the presence of pinprick sensation in sacral segments predict ambulation.

Organisation of care

• Multidisciplinary team: physician, nurse, physiotherapist, occupational therapist, speech and language therapist, dietitian, psychologist, social worker and orthotist.
• After stroke, offer at least 45 minutes of each required therapy daily, up to about 3 hours per day of combined therapy, for 5 to 6 days per week.
• Plan discharge early with home assessment, equipment, caregiver training and a community follow-up programme.

Motor and mobility training

• Task-specific practice, treadmill training with body weight support, overground gait training, and balance training.
• Constraint-induced movement therapy for selected patients with some active wrist and finger extension.
• Mirror therapy, motor imagery, functional electrical stimulation, and robot-assisted therapy as adjuncts.
• Orthoses: ankle foot orthosis for foot drop, resting hand splints for flexor spasm.
• Transcranial magnetic stimulation and vagus nerve stimulation are options in selected centres.

Spasticity

• Stretching, positioning, serial casting, and avoidance of noxious triggers such as constipation, infection and pressure sores.
• Baclofen 5 mg three times daily, increased every 3 days to a maximum of 80 mg/day. Tizanidine 2 mg at night, titrated to 36 mg/day in divided doses. Dantrolene 25 mg daily titrated to 100 mg four times daily when sedation limits other agents.
• Focal spasticity: botulinum toxin type A, for example onabotulinumtoxinA 200 to 400 units per session divided across muscles, repeated no sooner than every 12 weeks, combined with stretching and therapy.
• Severe generalised spasticity: intrathecal baclofen after a screening bolus of 50 micrograms. Surgical options include tendon lengthening and selective neurotomy.

Dysphagia, speech and cognition

• Texture-modified diet and thickened fluids per swallow assessment, chin tuck and compensatory manoeuvres, and swallowing exercises. Enteral feeding via nasogastric tube, with gastrostomy if swallowing remains unsafe beyond 2 to 4 weeks.
• Intensive speech therapy for aphasia, with augmentative communication aids when needed.
• Visual scanning training and prism adaptation for neglect, and cognitive rehabilitation for attention and executive function.

Pain

• Shoulder: supportive positioning, avoidance of overhead pulleys and forceful pulling on the hemiplegic arm, and intra-articular or subacromial triamcinolone 40 mg for capsulitis or bursitis.
• Neuropathic and central pain: amitriptyline 10 to 75 mg at night, gabapentin 300 mg at night titrated to 1800 mg/day or higher, pregabalin 150 to 600 mg/day, or lamotrigine 25 mg daily titrated to 200 mg/day.
• Complex regional pain syndrome: prednisolone 30 to 40 mg daily for 2 to 4 weeks, early mobilisation and desensitisation.

Mood and fatigue

• Sertraline 50 to 200 mg daily or escitalopram 10 to 20 mg daily for depression, plus psychological therapy.
• Fluoxetine is not used for motor recovery because it does not improve function and increases fracture risk.
• Modafinil or graded exercise for refractory fatigue, after exclusion of sleep apnoea, anaemia, hypothyroidism and drug effects.

Bladder, bowel and skin

• Intermittent catheterisation every 4 to 6 hours for retention. Oxybutynin 5 mg two to three times daily or mirabegron 25 to 50 mg daily for detrusor overactivity.
• Scheduled toileting, high fibre diet, macrogol, senna, and bisacodyl suppository 10 mg to establish a bowel routine.
• Pressure area care with turning every 2 hours, redistribution surfaces and heel offloading.

Prevention of complications

• Thromboprophylaxis with enoxaparin 40 mg SC daily when bleeding risk allows, and intermittent pneumatic compression in immobile stroke patients.
• Vitamin D 800 to 2000 IU daily and calcium. Zoledronic acid 5 mg IV yearly or alendronate 70 mg weekly for established osteoporosis.
• Secondary prevention of the underlying disease, including blood pressure, lipids and antithrombotic therapy.
• Falls prevention with strength and balance programmes, home modification and medication review.

Cardiac and pulmonary rehabilitation

• Cardiac: 8 to 12 weeks of supervised moderate intensity aerobic exercise, 2 to 3 sessions weekly, at about 60 to 80% of maximal heart rate or perceived exertion 11 to 14, with risk factor counselling. It reduces cardiovascular mortality and readmission after myocardial infarction.
• Pulmonary: 6 to 8 weeks of exercise and education, 2 to 3 sessions weekly. It improves 6 minute walk distance by about 40 to 50 metres and reduces breathlessness and readmission in COPD.

Amputee rehabilitation

• Early residual limb shaping, then prosthetic fitting at 6 to 12 weeks, gait training and phantom pain management (gabapentin, amitriptyline, mirror therapy).

Reintegration

• Driving assessment after stroke or seizure, vocational counselling and graded return to work, and peer support.
• Reassess at 3, 6 and 12 months. Chronic maintenance therapy and tele-rehabilitation sustain gains.