stroke recovery stroke recovery the primary goals of stroke management are to reduce brain injury and promote maximum patient recovery. rapid detection and appropriate emergency medical care are essential for optimizing health outcomes. when available, patients are admitted to an acute stroke unit for treatment. these units specialize in providing medical and surgical care aimed at stabilizing the patient's medical status. standardized assessments are also performed to aid in the development of an appropriate care plan. current research suggests that stroke units may be effective in reducing in-hospital fatality rates and the length of hospital stays. stroke recoveryother namesstroke rehabilitationstroke habilitationspecialtyneurologymeshd000071939medlineplus007419 once a patient is medically stable, the focus of their recovery shifts to rehabilitation. some patients are transferred to in-patient rehabilitation programs, while others may be referred to out-patient services or home-based care. in-patient programs are usually facilitated by an interdisciplinary team that may include a physician, nurse, pharmacist, physical therapist, occupational therapist, speech and language pathologist, psychologist, and recreation therapist. the patient and their family/caregivers also play an integral role on this team. family/caregivers that are involved in the patient care tend to be prepared for the caregiving role as the patient transitions from rehabilitation centers. while at the rehabilitation center, the interdisciplinary team makes sure that the patient attains their maximum functional potential upon discharge. the primary goals of this sub-acute phase of recovery include preventing secondary health complications, minimizing impairments, and achieving functional goals that promote independence in activities of daily living. in the later phases of stroke recovery, patients are encouraged to participate in secondary prevention programs for stroke. follow-up is usually facilitated by the patient's primary care provider. the initial severity of impairments and individual characteristics, such as motivation, social support, and learning ability, are key predictors of stroke recovery outcomes. responses to treatment and overall recovery of function are highly dependent on the individual. current evidence indicates that most significant recovery gains will occur within the first 12 weeks following a stroke. history of stroke neuro-rehabilitation in 1620, johann jakob wepfer, by studying the brain of a pig, developed the theory that stroke was caused by an interruption of the flow of blood to the brain. after that, the focus became how to treat patients with stroke. for most of the last century, people were discouraged from being active after a stroke. around the 1950s, this attitude changed, and health professionals began prescription of therapeutic exercises for stroke patient with good results. at that point, a good outcome was considered to be achieving a level of independence in which patients are able to transfer from the bed to the wheelchair without assistance. in the early 1950s, twitchell began studying the pattern of recovery in stroke patients. he reported on 121 patients whom he had observed. he found that by four weeks, if there is some recovery of hand function, there is a 70% chance of making a full or good recovery. he reported that most recovery happens in the first three months, and only minor recovery occurs after six months. more recent research has demonstrated that significant improvement can be made years after the stroke. around the same time, brunnstrom also described the process of recovery, and divided the process into seven stages. as knowledge of the science of brain recovery improved, intervention strategies have evolved. knowledge of strokes and the process of recovery after strokes has developed significantly in the late 20th century and early 21st century. current perspectives and therapeutic avenues motor re-learning "neurocognitive rehabilitation by carlo perfetti concept", widespread in many countries, is an original motor re-learning theories application. constraint-induced movement therapy main article: constraint-induced movement therapy the idea for constraint-induced therapy is at least 100 years old. significant research was carried out by robert oden. he was able to simulate a stroke in a monkey's brain, causing hemiplegia. he then bound up the monkey's good arm, and forced the monkey to use his bad arm, and observed what happened. after two weeks of this therapy, the monkeys were able to use their once hemiplegic arms again. this is due to neuroplasticity. he did the same experiment without binding the arms, and waited six months past their injury. the monkeys without the intervention were not able to use the affected arm even six months later. in 1918, this study was published, but it received little attention. eventually, researchers began to apply his technique to stroke patients, and it came to be called constraint-induced movement therapy. notably, the initial studies focused on chronic stroke patients who were more than 12 months past their stroke. this challenged the belief held at that time that no recovery would occur after one year. the therapy entails wearing a soft mitt on the good hand for 90% of the waking hours, forcing use of the affected hand. the patients undergo intense one-on-one therapy for six to eight hours per day for two weeks. evidence that supports the use of constraint induced movement therapy has been growing since its introduction as an alternative treatment method for upper limb motor deficits found in stroke populations. recently, constraint induced movement therapy has been shown to be an effective rehabilitation technique at varying stages of stroke recovery to improve upper limb motor function and use during activities of daily living. these may include, but are not limited to, eating, dressing, and hygiene activities. cimt may improve motor impairment and motor function, but the benefits have not been found to convincingly reduce disability, with further research required. using functional activities as part of the cimt treatment has been shown to enhance functional outcomes in one's activities of daily living. occupational therapists are uniquely qualified to provide function-based treatment in conjunction with a cimt approach. the greatest gains are seen among persons with stroke who exhibit some wrist and finger extension in the affected limb. transcranial magnetic stimulation and brain imaging studies have demonstrated that the brain undergoes plastic changes in function and structure in patients that perform constraint induced movement therapy. these changes accompany the gains in motor function of the paretic upper limb. however, there is no established causal link between observed changes in brain function/structure and the motor gains due to constraint induced movement therapy. constraint induced movement therapy has recently been modified to treat aphasia in patients post cva as well. this treatment intervention is known as constraint induced aphasia therapy (ciat). the same general principals apply, however in this case, the client is constricted from using compensatory strategies to communicate such as gestures, writing, drawing, and pointing, and are encouraged to use verbal communication. therapy is typically carried out in groups and barriers are used so hands, and any compensatory strategies are not seen. mental practice/mental imagery mental practice of movements, has been shown in many studies to be effective in promoting recovery of both arm and leg function after a stroke. it is often used by physical or occupational therapists in the rehab or homehealth setting, but can also be used as part of a patient's independent home exercise program. mental movement therapy is one product available for assisting patients with guided mental imagery. electrical stimulation such work represents a paradigm shift in the approach towards rehabilitation of the stroke-injured brain away from pharmacologic flooding of neuronal receptors and instead, towards targeted physiologic stimulation. in layman's terms, this electrical stimulation mimics the action of healthy muscle to improve function and aid in retraining weak muscles and normal movement. functional electrical stimulation (fes) is commonly used in 'foot-drop' following stroke, but it can be used to help retrain movement in the arms or legs. bobath (ndt) main article: bobath concept in patients undergoing rehabilitation with a stroke population or other central nervous system disorders (cerebral palsy, etc.), bobath, also known as neurodevelopmental treatment (ndt), is often the treatment of choice in north america. the bobath concept is best viewed as a framework for interpretation and problem solving of the individual patient's presentation, along with their potential for improvement. components of motor control that are specifically emphasized, are the integration of postural control and task performance, the control of selective movement for the production of coordinated sequences of movement and the contribution of sensory inputs to motor control and motor learning. task practice is a component of a broad approach to treatment that includes in-depth assessment of the movement strategies utilized by the patient to perform tasks, and identification of specific deficits of neurological and neuromuscular functions. many studies have been conducted comparing ndt with other treatment techniques such as proprioceptive neuromuscular facilitation (pnf stretching), as well as conventional treatment approaches (utilizing traditional exercises and functional activities), etc. despite being widely used, based on the literature, ndt has failed to demonstrate any superiority over other treatment techniques available. in fact, the techniques compared with ndt in these studies often produce similar results in terms of treatment effectiveness. research has demonstrated significant findings for all these treatment approaches when compared with control subjects and indicate that overall, rehabilitation is effective. it is important to note, however, that the ndt philosophy of "do what works best" has led to heterogeneity in the literature in terms of what constitutes an ndt technique, thus making it difficult to directly compare to other techniques. mirror therapy mirror therapy (mt) has been employed with some success in treating stroke patients. clinical studies that have combined mirror therapy with conventional rehabilitation have achieved the most positive outcomes. however, there is no clear consensus as to its effectiveness. in a recent survey of the published research, rothgangel concluded thatin stroke patients, we found a moderate quality of evidence that mt as an additional therapy improves recovery of arm function after stroke. the quality of evidence regarding the effects of mt on the recovery of lower limb functions is still low, with only one study reporting effects. in patients with crps and plp, the quality of evidence is also low. robotic rehabilitation robot-assisted training enables stroke patients with moderate or severe upper limb impairment to perform repetitive tasks in a highly consistent manner, tailored to their motor abilities. high intensity repetitive task practice delivered via robot-assisted therapy is recommended to improve motor function in individuals in the inpatient, outpatient and chronic care settings. these therapies have achieved the highest level of evidential support by the american heart association (class i, level of evidence a) for the outpatient and chronic care settings and class iia level of evidence for the inpatient setting. electromechanical and robot-assisted arm training may improve arm function (measured using the 'arm function outcome measure') and may significantly improve activities of daily living (adl) scores. stem cells therapies (in research) use of bone-marrow derived mesenchymal stem cells (mscs) in the treatment of ischemic stroke the terminal differentiation of some somatic stem cells has recently been called into question after studies of transplanted haematopoietic stem cells showed the development of myoblasts, endothelium, epithelium and neuroectodermal cells, suggesting pluripotency. these findings have led to mscs being considered for treatment of ischemic stroke, specifically in directly enhancing neuroprotection and the neurorestorative processes of neurogenesis, angiogenesis and synaptic plasticity. possible mechanisms of neurorestoration and neuroprotection by mscs after stroke transdifferentiation of mscs into excitable neuron-like cells has been shown to be possible in vitro and these cells respond to common central nervous system neurotransmitters. however, it is unlikely that this degree of transdifferentiation occurs in vivo and that <1% of injected mscs become truly differentiated and integrate in the damaged area. this suggests that transdifferentiation of mscs into neurons or neuron-like cells is not a major mechanism by which mscs cause neurorestoration. induction of neurogenesis (development of new neurons) is another possible mechanism of neurorestoration; however its correlation with functional improvement after stroke is not well established. the inducted cells likely originate from the ventricular zone, subventricular zone and choroid plexus, and migrate to the areas in their respective hemispheres which are damaged. unlike the induction of neurogenesis, the induction of angiogenesis (development of new blood vessels) by mscs has been associated with improvements in brain function after ischemic strokes and is linked to improved neuronal recruitment. in addition, synaptogenesis (formation of new synapses between neurons) has been shown to increase after msc treatment; this combination of improved neurogenesis, angiogenesis and synaptogenesis may lead to a