How long after a stroke is recovery possible? This is a common question individuals ask in physical therapy after experiencing a stroke. Usually, they have heard that most progress happens in the first 6 months. To me, this is a complicated question to answer. I have found, clinically, individuals can make progress after 6 months, but this is not always communicated appropriately to people after they have had a stroke. Research does show that spontaneous recovery occurs in the first 3 months post stroke.¹ Therefore, individuals in the acute and subacute phases are going to show more progress in rehab at this time. So what does this mean for people post stroke that fall beyond this timeline, also known as a chronic stroke? Research has shown at this stage, recovery slows or plateaus in comparison to the acute phase.² However, this does not mean that you cannot make significant progress in their physical therapy during this time.
Prevalence and Morbidity
There are approximately 795,000 people that experience a stroke in the United States each year.³ Up to 50% of stroke survivors experience chronic disabilities.⁴ Physical disabilities are often related to balance and gait issues. With these type of impairments, we see decreased quality of life scores and difficulty participating in daily life.⁵ Given this information, the chronic stroke population cannot be ignored in the physical therapy community. So how can we help these individuals with research telling us that recovery slows at this stage?
Walking
The American Physical Therapy Association (APTA) released a clinical practice guideline (CPG) for chronic stroke that provides recommendations on the best strategy of care for this population in regards to locomotor function.⁶ Based on their research, walking at moderate to high intensity (60-80% of heart rate reserve) seems to be the best way to see results. Walking duration varied from 20-60 minutes and was performed anywhere from 2-5x a week over 1 to 6 months in the studies reviewed. Sessions could be performed overground or on treadmill. Improvements were seen in 6 minute walk test, 10 minute walk test, and walking speed. Most of the studies focused on consistent walking staying in the 60-80% of heart rate reserve range. Two studies had a slightly different protocol focusing on interval treadmill training. When compared to the same treatment but performed at a lower intensity, the higher intensity groups demonstrated more progress in gait.
So how do we apply this information to our patients? I think the first step is to evaluate if we are pushing this patient population enough to evoke a change. Perhaps, this is the reason a plateau is occurring in physical therapy with these individuals. It is vital that we are measuring target heart rates to monitor the intensity of the exercise routine. As we see above, if the walking program is too easy, it is not going to make a significant difference.
Balance
Balance issues are another long term consequence of chronic stroke. Can these be improved in the chronic stage as well? Research says yes. A systematic review and meta-analysis was performed on the effects of exercise therapy on balance in the chronic stroke population.⁷ Training strategies were categorized as balance and/or functional weight-shifting training, gait training, multi sensory training, high-intensity aerobic training, and other training programs. The chronicity after stroke ranged between 7 months to 7.7 years. Balance, as tested by Berg Balance Scale, Functional Reach Test, and Sensory Organization Test, improved after programs focusing on balance/weight shifting and gait training. Based on this information we can say that working on balance can improve in individuals with chronic stroke. However, because this study included such a variety of different balance interventions, it is difficulty to say what interventions would be the most efficient and effective to improve balance. Perhaps, future studies will provide more insight on this topic. In the mean time, it may be best to focus on what we know about neuroplasticity and task specific training. Task specific training has shown to promote motor learning and cortical reorganization.⁸ For this reason, focusing on static and dynamic balance tasks that individuals experience in daily life would be the best to focus on in their physical therapy interventions.
Neuromuscular Electrical Stimulation
Another treatment strategy that has helped individuals with chronic stroke is neuromuscular electrical stimulation or NMES. A systematic review looked at the effect of NMES on lower limb function.⁹ To evaluate the effect on lower limb function, gait speed, balance, spasticity and range of motion, and walking endurance were used. The review found an improvement in gait speed, balance, tone, and range of motion. Measures to evaluate improvements were gait analysis, 10 minute walk test, 6 minute walk test, Berg Balance Scale, Timed up and go, and Modified Ashworth. An important note of this systematic review is that NMES was only effective when combined with other treatment strategies than with NMES alone. Using this information, we can use NMES as an adjunct to physical therapy interventions. It can be used to assist with motions that may be difficult for individuals in functional tasks. For example, applying electrodes to dorsiflexors can assist with foot drop during heel strike in gait. In addition, using electrodes on finger extensors to open hand to prepare for gripping activities.
Conclusion
I hope that providing this information changes clinicians minds about chronic stroke and the possibility of continued recovery. I think that this population is often ignored because we are told that progression is not going to happen after 6 months. However, we have seen in research that it can. We have to change our treatment strategies for these individuals in order to challenge them and promote improvements. Hopefully, future studies will continue to give guidance on why these patients may reach a plateau in therapy and how we can avoid it.
Audriana Spadaro is an outpatient physical therapist who works mostly with individuals with neurological disorders. She graduated from University of Michigan-Flint with her Doctor of Physical Therapy degree in 2016. She has been with Henry Ford Health for 6 years. She is certified in LSVT BIG and PWR!Moves. In her free time, she enjoys hiking, horseback riding, walking her dog and chasing around her 1 year old son.
References
- Cramer SC. Repairing the human brain after stroke: I. Mechanisms of spontaneous recovery. Ann Neurol. 2008 Mar;63(3):272-87. doi: 10.1002/ana.21393. PMID: 18383072.
- Teasell RW, Murie Fernandez M, McIntyre A, Mehta S. Rethinking the continuum of stroke rehabilitation. Arch Phys Med Rehabil. 2014 Apr;95(4):595-6. doi: 10.1016/j.apmr.2013.11.014. Epub 2014 Feb 14. PMID: 24529594.
- Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, et al. Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association. Circulation. 2022;145(8):e153–e639.
- Donkor ES. Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life. Stroke Res Treat. 2018 Nov 27;2018:3238165. doi: 10.1155/2018/3238165. PMID: 30598741; PMCID: PMC6288566.
- Schmid AA, Van Puymbroeck M, Altenburger PA, Miller KK, Combs SA, Page SJ. Balance is associated with quality of life in chronic stroke. Top Stroke Rehabil. 2013 Jul-Aug;20(4):340-6. doi: 10.1310/tsr2004-340. PMID: 23893833.
- Hornby TG, Reisman DS, Ward IG, Scheets PL, Miller A, Haddad D, Fox EJ, Fritz NE, Hawkins K, Henderson CE, Hendron KL, Holleran CL, Lynskey JE, Walter A; and the Locomotor CPG Appraisal Team. Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury. J Neurol Phys Ther. 2020 Jan;44(1):49-100. doi: 10.1097/NPT.0000000000000303. PMID: 31834165.
- van Duijnhoven HJ, Heeren A, Peters MA, Veerbeek JM, Kwakkel G, Geurts AC, Weerdesteyn V. Effects of Exercise Therapy on Balance Capacity in Chronic Stroke: Systematic Review and Meta-Analysis. Stroke. 2016 Oct;47(10):2603-10. doi: 10.1161/STROKEAHA.116.013839. Epub 2016 Sep 15. PMID: 27633021.
- Takeuchi N, Izumi S. Rehabilitation with poststroke motor recovery: a review with a focus on neural plasticity. Stroke Res Treat. 2013;2013:128641. doi: 10.1155/2013/128641. Epub 2013 Apr 30. PMID: 23738231; PMCID: PMC365950
- Hong Z, Sui M, Zhuang Z, Liu H, Zheng X, Cai C, Jin D. Effectiveness of Neuromuscular Electrical Stimulation on Lower Limbs of Patients With Hemiplegia After Chronic Stroke: A Systematic Review. Arch Phys Med Rehabil. 2018 May;99(5):1011-1022.e1. doi: 10.1016/j.apmr.2017.12.01 Epub 2018 Jan 31. PMID: 29357280.
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