Each year, almost 800,000 Americans suffer a stroke1 — an interruption of blood flow to the brain that is often associated with difficulties with movement, language, cognition, and sometimes all three. Approximately half of all stroke survivors experience impaired mobility long after their stroke. Another common issue experienced by many stroke survivors is a prolonged reduction in cognitive abilities such as memory, problem-solving, and spatial orientation. Together, these and other common consequences of stroke mean that everyday activities, such as standing and walking, dressing, grooming, and meal preparation, may become difficult or impossible. Hence, stroke is a leading cause of long-term disability in the United States1. The American Heart Association estimates that stroke-associated health care services, medical interventions, and lost productivity cost the country an estimated $56.2 billion between 2019-20202.
Today, rehabilitation therapy is a core component of medical care after stroke. Post-stroke rehabilitation is typically a complex process, often involving a team of specialized physicians and therapists from the disciplines of neurology, physical medicine and rehabilitation, physical therapy, occupational therapy, speech therapy, psychology, and others. The modern approach to post-stroke rehabilitation comes from decades of federal investment in scientific research, systematically investigating the underlying mechanisms of stroke-related impairments as well as the efficacy of different treatment approaches, but the work is far from over. Indeed, the numbers cited above highlight the need for continued investment in stroke rehabilitation research. We cannot fix a problem without first understanding it. Continuing to improve post-stroke outcomes and reducing long-term healthcare costs can only happen by advancing knowledge of how to best diagnose and treat an individual’s deficits after stroke.
Rehabilitation research revolutionized care for stroke survivors
Up to the mid-20th century, post-stroke medical care was primarily palliative in nature – very little was attempted as far as retraining or rehabilitation3. Yet, around this time, practitioners in the burgeoning field of rehabilitation therapy were showing that physical interventions could improve function in a variety of disabling conditions, from paralysis secondary to polio to the neurologic and orthopedic injuries suffered by scores of Veterans of World Wars I and II. Building on these findings, American Internist, Howard Rusk, MD (now considered one of the fathers of comprehensive rehabilitation medicine), was among the first clinicians to investigate the utility of physical techniques and simple equipment (e.g., pulley supports to lift paretic arms) in helping stroke survivors compensate for their movement control deficits. Dr. Rusk’s work showed that these interventions could greatly improve functional ability post-stroke, beginning the field of stroke rehabilitation.
By the 1970s and 1980s, research on post-stroke rehabilitation, including randomized clinical trials of stroke rehabilitation therapies, had exploded3. This work made clear the benefits of multidisciplinary stroke rehabilitation teams in both inpatient and outpatient clinical care. As a result, many hospitals in the U.S. and around the world began facilitating the transition between acute medical care and rehabilitation. The result, according to one Danish study4, was a 30% reduction in hospital stays, a 40% reduction in the risk of discharge to assisted living facilities, and a 50% reduction in the relative risk of death following stroke.
Research continues to advance post-stroke rehabilitation today
Much early research was devoted to understanding how strokes affect movement or cognitive ability, treating them as siloed elements of functional ability. However, innovative research is beginning to focus on how problems in each of these areas may overlap, with each affecting the other. For example, previous research investigated whether repetitive practice (such as reaching for objects many hundreds of times a day) could improve movement performance3. While individuals do improve with such practice regimens, the gains typically do not last—resulting in losses of substantial investments of time and money.
In daily life, we typically perform movements in the context of a cognitive task and vice versa, such as locating and reaching for a specific type of food in the refrigerator or reading road signs while out for a walk. Accordingly, recent research suggests that recovery from movement and cognitive impairments after stroke can benefit from an integrated approach that takes into account both domains of functioning5. For instance, it is not surprising that asking people to perform a distracting task (such as repeating numbers) while they reach for objects or walk may slow their movement and cause errors. Remarkably, however, practicing in these distracting conditions can actually lead to longer-lasting improvements after stroke. Strengthening the ability to do both cognitive and motor tasks together is a targeted intervention that matches the demands of integrating those tasks in daily life.
Considering both motor and cognitive functioning—and their impact on one another—reflects an exciting shift in our appreciation of how to best treat post-stroke deficits. Researchers at Jefferson Moss Rehabilitation Research Institute, fueled by critical federal investments in motor and cognitive stroke research, are leading the way in scientific discoveries such as these, and in the translation of these discoveries into cutting-edge clinical treatments.
References:
1. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics—2023 update: a report from the American Heart Association. Circulation. 2023;147:e93–e621.
2. Martin SS, Aday AW, Almarzooq ZI, et al.; American Heart Association Council on Epidemiology and Prevention Statistics Committee; Stroke Statistics Subcommittee. 2024 heart disease and stroke statistics: a report of US and global data from the American Heart Association. Circulation 2024;149:e347–913.
3. Lanska DJ. (2014) The Historical Origins of Stroke Rehabilitation. In Stein J, Harvey RL, Winstein CJ, Zorowitz RD, Wittenberg GF. (Eds), Stroke Recovery and Rehabilitation, 2nd Ed. Springer Publishing.
4. Jorgensen HS, Nakayama H, Raaschou HO, Larsen K, Hübbe P, Olsen TS. The effect of a stroke unit: reductions in mortality, discharge rate to nursing home, length of hospital stay, and cost. Stroke. 1995;26(7):1178–1182.
5. Eschweiler M, Bohr L, Kessler J, Fink GR, Kalbe E, Onur OA. Combined cognitive and motor training improves the outcome in the early phase after stroke and prevents a decline of executive functions: A pilot study. NeuroRehabilitation. 2021;48(1):97-108.
Other Articles In This Series
Article 1: Reclaiming Lives: Neurorehabilitation Research is Critical to Advancing Care