Rehabilitation approaches to stroke

This article describes the state of the science in stroke rehabilitation dealing with three main topics: (1) General approach to stroke rehabilitation (stroke services and stroke units), (2) Neurophysiological and pharmacological interventions (facilitation of brain repair mechanisms) and (3) Experimental approaches (neuronal transplantation). Stroke rehabilitation is an active process beginning during acute hospitalisation, progressing to a systematic program of rehabilitation services and continuing after the individual returns to the community. There is world-wide consensus that stroke patients should be treated at specialised stroke unit with specially trained medical and nursing staff, co-ordinated multidisciplinary rehabilitation and education programs for patients and their families. Stroke Unit has been shown to be associated with a long-term reduction of death and of the combined poor outcomes of death and dependency, independent of patients age, sex, or variations in stroke unit organisations. No study has clearly shown to what extent the beneficial effect is due to specific rehabilitation strategies. New imaging studies in stroke patients indicate altered post stroke activation patterns, which suggest some functional reorganisation. Reorganisation may be the principle process responsible for recovery after stroke. It is assumed that different post ischaemic interventions like physiotherapy, occupational therapy, speech therapy, electrical stimulation, etc. facilitates such changes. Scientific evidence demonstrating the values of specific rehabilitation interventions after stroke is limited. Comparisons between different methods in current use have so far mostly failed to show that any particular physiotherapy, occupational therapy, speech therapy or stroke rehabilitation strategy is superior to another. Clinical data are strongly in favour of early mobilisation and training. Pharmacological interventions in animals revealed that norepinephrine, amphetamine and other alpha-adrenergic stimulating drugs can enhance motor performance after unilateral ablation of the sensory motor cortex. The clinical data in humans are rather contradictory. Neural grafting and neurogenesis are new potential modes of stroke therapy. Neural grafting enhanced functional outcome and reduced thalamic atrophy in rats only when combined with housing in enriched environments. Recent studies have shown that stem cells can differentiate to neurons in the adult human dentate gyrus in vivo.