a direct correlation between shoulder subluxation and pain. the exact cause of subluxation in post-stroke patients is unclear but appears to be caused by weakness of the musculature supporting the shoulder joint. the shoulder is one of the most mobile joints in the body. to provide a high level of mobility the shoulder sacrifices ligamentous stability and as a result relies on the surrounding musculature (i.e., rotator cuff muscles, latissimus dorsi, and deltoid) for much of its support. this is in contrast to other less mobile joints such as the knee and hip, which have a significant amount of support from the joint capsule and surrounding ligaments. if a stroke damages the upper motor neurons controlling muscles of the upper limb, weakness and paralysis, followed by spasticity occurs in a somewhat predictable pattern. the muscles supporting the shoulder joint, particularly the supraspinatus and posterior deltoid become flaccid and can no longer offer adequate support leading to a downward and outward movement of arm at the shoulder joint causing tension on the relatively weak joint capsule. other factors have also been cited as contributing to subluxation such as pulling on the hemiplegic arm and improper positioning. diagnosis can usually be made by palpation or by feeling the joint and surrounding tissues, although there is controversy as to whether or not the degree of subluxation can be measured clinically. if shoulder subluxation occurs, it can become a barrier to the rehabilitation process. treatment involves measures to support the subluxed joint such as taping the joint, using a lapboard or armboard. a shoulder sling may be used, but is controversial and a few studies have shown no appreciable difference in range-of-motion, degree of subluxation, or pain when using a sling. a sling may also contribute to contractures and increased flexor tone if used for extended periods of time as it places the arm close to the body in adduction, internal rotation and elbow flexion. use of a sling can also contribute to learned nonuse by preventing the functional and spontaneous use of the affected upper extremity. that said, a sling may be necessary for some therapy activities. slings may be considered appropriate during therapy for initial transfer and gait training, but overall use should be limited. as the patient begins to recover, spasticity and voluntary movement of the shoulder will occur as well as reduction in the shoulder subluxation. slings are of no value at this point. functional electrical stimulation (fes) has also shown promising results in treatment of subluxation, and reduction of pain, although some studies have shown a return of pain after discontinuation of fes. more recent research has failed to show any reduction of pain with the use of fes. logical treatment consists of preventive measures such as early range of motion, proper positioning, passive support of soft tissue structures and possibly early re-activation of shoulder musculature using functional electrical stimulation. aggressive exercises such as overhead pulleys should be avoided with this population. rehabilitation cognitive rehabilitation for spatial neglect following stroke the current body of evidence is uncertain on the efficacy of cognitive rehabilitation for reducing the disabling effects of neglect and increasing independence remains unproven. however, there is limited evidence that cognitive rehabilitation may have an immediate beneficial effect on tests of neglect. overall, no rehabilitation approach can be supported by evidence for spatial neglect. rehabilitation for improving automobile driving after stroke the current body of evidence is uncertain whether the use of rehabilitation can improve on-road driving skills following stroke. there is limited evidence that training on a driving simulator will improve performance on recognizing road signs after training. the findings are based on low-quality evidence as further research is needed involving large numbers of participants. yoga for stroke rehabilitation based on low quality evidence, it is currently uncertain whether yoga has a significant benefit for stroke rehabilitation on measures of quality of life, balance, strength, endurance, pain, and disability scores. yoga may reduce anxiety and could be included as part of patient-centred stroke rehabilitation. further research is needed assessing the benefits and safety of yoga in stroke rehabilitation. action observation for upper limb rehabilitation after stroke the latest scientific evidence indicates that action observation is beneficial in improving upper limb and hand function in patients with stroke. thus, action observation therapy is generally associated with better arm and hand function, with no significant adverse events. the findings are based on low to moderate quality evidence. cognitive rehabilitation for attention deficits following stroke the current body of scientific evidence is uncertain on the effectiveness of cognitive rehabilitation for attention deficits in patients following stroke. while there may be an immediate effect after treatment on attention, the findings are based on low to moderate quality and small number of studies. further research is needed to assess whether the effect can be sustained in day-to-day tasks requiring attention. motor imagery for gait rehabilitation after stroke the latest evidence supports the short-term benefits of motor imagery (mi) on walking speed in individuals who have had a stroke, in comparison to other therapies. mi does not improve motor function after stroke and does not seem to cause significant adverse events. the findings are based on low-quality evidence as further research is needed to estimate the effect of mi on walking endurance and the dependence on personal assistance. apraxia main article: apraxia an uncommon, less understood result of stroke is a condition called apraxia. this condition was initially recognized as: 'disorders of the execution of learned movements which cannot be accounted for by either weakness, incoordination, or sensory loss, nor by incomprehension of, or inattention to commands.' several forms of apraxia are recognized. limb-kinetic apraxia is the inability to make precise or exact movements with a finger, an arm or a leg. idiomotor apraxia is the inability to carry out a command from the brain to mimic limb or head movements performed or suggested by others. conceptual apraxia is similar to idiomotor apraxia, but infers a more profound malfunctioning in which the function of tools or objects is no longer understood. ideational apraxia is the inability to create a plan for a specific movement. buccofacial apraxia, or facial-oral apraxia, is the inability to coordinate and carry out facial and lip movements such as whistling, winking, coughing, etc. on command. constructional apraxia affects the person's ability to draw or copy simple diagrams, or to construct simple figures. oculomotor apraxia is a condition in which the patient finds it difficult to move his/her eyes. many believe that the most common form of apraxia is idiomotor apraxia, in which a disconnection between the area of the brain containing plans for a movement and the area of the brain that is responsible for executing that movement occurs. unlike many effects of stroke, where the clinician is able to judge the particular area of the brain that a stroke has injured by certain signs or symptoms, the causation of apraxia is less clear. a common theory is that the part of the brain that contains information for previously learned skilled motor activities has been either lost or cannot be accessed. the condition is usually due to an insult to the dominant hemisphere of the brain. more often this is located in the frontal lobe of the left hemisphere of the brain. treatment of acquired apraxia due to stroke usually consists of physical, occupational, and speech therapy. the copenhagen stroke study, which is a large important study published in 2001, showed that out of 618 stroke patients, manual apraxia was found in 7% and oral apraxia was found in 6%. both manual and oral apraxia were related to increasing severity of stroke. oral apraxia was related with an increase in age at the time of the stroke. there was no difference in incidence among gender. it was also found that the finding of apraxia has no negative influence on ability to function after rehabilitation is completed. the national institute of neurological disorders and stroke (ninds) is currently sponsoring a clinical trial to gain an understanding of how the brain operates while carrying out and controlling voluntary motor movements in normal subjects. the objective is to determine what goes wrong with these processes in the course of acquired apraxia due to stroke or brain injury. lateral medullary syndrome main article: lateral medullary syndrome lateral medullary syndrome, also known as wallenberg's syndrome, is caused by blockage of the posterior inferior cerebellar artery (pica) or the vertebral arteries. signs and symptoms include decreased pain and temperature on the same side of the face and opposite side of the body compared to the lesion, ataxia on the same side of the lesion, and horner's syndrome on the same side of the face. treatment in the acute setting is mostly focused on symptomatic management. after initial treatment in the hospital, some patients will need short-term placement in a nursing home or rehabilitation facility before going home. in hospital settings the doctors work with speech pathologists in issues like these. typically, a commonly used tool to assess the degree of severity of dysphagia and speech issues is the barnes jewish hospital stroke dysphagia screen, which offers a validated guide to assessing plan of action (solid food diet, all liquid diet, iv hydration, etc.) for the patient while in the hospital and the proper course of action in the outpatient setting. rehabilitation in wallenberg's syndrome focuses on improving balance, coordination, working on activities of daily living, and improving speech and swallowing function. severe nausea and vertigo can be present and limit progress in rehabilitation and recovery. symptomatic treatment with anti-emetics and medications for the hiccups are important. commonly used anti-emetics include ondansetron, metoclopramide, prochlorperazine, and promethazine. these medications are also used to treat hiccups, along with chlorpromazine. there are case reports of other medications useful in treating hiccups in wallenberg's syndrome including baclofen and anti-epileptic medications. the prognosis for someone with lateral medullary syndrome depends upon the size and location of damaged area of the brain stem. some individuals recover quickly while others may have significant neurological disabilities for months to years after the initial injury. post-stroke depression main article: post-stroke depression depression is a commonly reported consequence of stroke and is seen in 25–50% of patients. the diagnostic and statistical manual (dsm-iv-tr) defines post-stroke depression as "a mood disorder due to a general medical condition (i.e. stroke) that is judged to be due to the direct physiological effects of condition". post-stroke depression may involve depressed mood and decreased interest and pleasure that impairs social and occupational functioning, but does not necessarily need to meet the full criteria of a major depressive disorder. the first studies to look for an association between specific stroke lesions and the occurrence of depression reported a correlation between left frontal lesions and major depression. damage to the frontal noradrenergic, dopaminergic, and serotonergic projections were thought to cause a depletion of catecholamines, leading to depression. however, more recent studies have demonstrated that the anatomic aspects of a lesion do not necessarily correlate with the occurrence of depression. other psychological factors can lead to the development of depression including personal and social losses related to the physical disabilities often caused by a stroke. the incidence of post-stroke depression peaks at 3–6 months and usually resolves within 1–2 years after the stroke, although a minority of patients can go on to develop chronic depression. the diagnosis of post-stroke depression is complicated by other consequences of stroke such as fatigue and psychomotor retardation – which do not necessarily indicate the presence of depression. loss of interest in activities and relationships should prompt an evaluation for depression. traditionally, tricyclic antidepressants (tcas), such as nortriptyline, have been used in the treatment of post-stroke depression. more recently, the selective serotonin reuptake inhibitors (ssris), such as fluoxetine and citalopram, have become the pharmacologic therapy of choice due to the lower incidence of side effects. also, psychologic treatment such as cognitive behavioral therapy, group therapy, and family therapy are reported to be useful adjuncts to treatment. overall, the development of post-stroke depression can play a significant role in a patient's recovery from a stroke. the severity of post-stroke depression has been associated with severity of impairment in activities of daily living (adls). by effectively treating depression, patients experience a greater recovery of basic adls such as dressing,