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Early Integration of Physical, Occupational, and Speech Therapies on Stroke Patients’ Recovery

On my first day at the hospital, the letters “CVA” were written across the nursing assistant sheet in the diagnosis box. I asked the nursing assistant what it stood for and he said it meant the patient had a stroke prior to being transferred to our floor, the Physical Medicine Rehabilitation Unit. Over the next few months, I vividly saw similarities of symptoms between patients who had a right frontal stroke: a flaccid left arm, overall left-sided weakness, and sometimes aphasia, difficulty comprehending speech and/or dysarthria, difficulty speaking due to stroke-induced brain damage. In the mornings, these patients would work with physical, occupational, and speech therapists for an average of three hours per day. As a nursing assistant, I ensured that the patient’s left arm was propped on a pillow when sitting upright in the recliner, opened their food containers, and used the stand assist lift or rolling walker for transfers to the bed, recliner, or bathroom/bedside commode depending on their mobility status. I saw how all of the hospital staff had a specific role in helping these patients get discharged as soon as possible and I began to wonder how effective the combination of all these therapies would be on their recovery process, especially if integrated early on.


What roles do physical, occupational, and speech therapists have in relation to stroke patients? Physical therapists help these patients regain their previously lost motor skills and muscle mobility through targeted, high intensity, and repeated physical exercise and body movements [1]. Occupational therapists focus on having patients engage in activities of daily living (ADLs) such as folding clothes, dressing themselves, showering, and leisure work such as cooking and baking in order for them to more easily adjust to life back at home. Speech therapists work with patients who have difficulty communicating (aphasia or dysarthria) or swallowing, which are both common impairments caused by strokes. Although there is generally strong evidence that early interventions of physical therapy and occupational therapy contribute to positive outcomes, there is no clear conclusion for the early effect of speech therapies. According to Godecke et al.’s randomized control trial on patients with aphasia, there was no statistically different outcome for patients who received usual aphasia care versus those who received very early rehabilitation intensive therapies (VERSE), with no benefit seen in 12-26 weeks post-stroke related to language impairment, discourse/connected speech, quality of life, and depression [2]. Therefore, more research and innovations need to be done in this field as patients with aphasia are known to have greater mortality rates, lower return-to-work rates and social participation, and are three times more likely to experience depression [2], which greatly affect the person’s quality of life post-stroke. However, with all these post-stroke physical, occupational, and speech therapy studies, it is important to note a common limitation mentioned in many papers: there is not a clearly standardized and specific method of measuring each of the outcomes. This results in inconsistent results if these therapies are actually more or less effective if implemented earlier in the recovery process.


Among the scientific community, clinical trials have been conducted to determine the optimal “golden time” to start post-stroke rehabilitation interventions. According to Langhorne et al., a stroke patient’s recovery of body functions and activities can be predicted within the first few days [1], indicating the importance of immediate implementation of post-stroke therapies. Liu et al. found that within 2 weeks post-stroke, patients benefited greatly from constraint-induced movement therapy (CIMT) for the upper limbs, which is when the affected limb gets more repetitive, intensive therapy and the non-affected arm is restricted [3, 4]. Positive health outcomes for patients has been proven by a coordinated and well-functioning multidisciplinary care team consisting of medical, nursing, therapy, and social workers who work with patients to tailor their goals through task and context-specific training with the end goal of early supported discharge. Through this process, patients are able to return to their homes as soon as possible, equipped with the skills they learned through their hospital physical and occupational therapy sessions and implement it in their own homes [1].


Seeing the smiles on patients’ faces after having successfully completed a physical therapy task or having started to use the rolling walker instead of the stand assist lift, which does not require any walking, has been one of the biggest joys of working at the hospital. It is bittersweet to see all the patients’ hard work pay off when they are getting ready to be discharged, but I am confident that they will leave our unit having learned all the skills of safe practices and exercises to continuously implement and improve at in the comfort of their own homes, as post-stroke recovery can take up to months and years. In this technological day and age, the use of virtual reality and robots as therapeutic interventions, such as through a game with points that requires the patient to use their muscles, could be the next step towards making the recovery process more engaging for patients. Although currently, there is evidence that these technological therapies aren’t as useful as traditional forms of physical, occupational, and speech therapies, hopefully these interventions can be more universally accessible and well-developed to help stroke patients recover in a quicker, more efficient, and enjoyable manner [5].


References

1. Langhorne, P., Bernhardt, J., & Kwakkel, G. (2011). Stroke rehabilitation. The Lancet,

377(9778), 1693–1702. https://doi.org/10.1016/S0140-6736(11)60325-5

2. Godecke, E., Armstrong, E., Rai, T., Ciccone, N., Rose, M.L., Middleton, S., Whitworth, A., Holland, A., Ellery, F., Hankey, G.J., Cadilhac, D.A., Bernhardt, J., on behalf of the VERSE Collaborative Group. (2021). A randomized control trial of intensive aphasia therapy after acute stroke: The Very Early Rehabilitation for SpEech (VERSE) study. International Journal of Stroke, 16(5), 556-572. doi:10.1177/1747493020961926

3. Liu, Y., Yin, J.-H., Lee, J.-T., Peng, G.-S., & Yang, F.-C. (2022). Early Rehabilitation after

Acute Stroke: The Golden Recovery Period. Acta Neurologica Taiwanica, advanced

online publication. https://pubmed.ncbi.nlm.nih.gov/34918304/

4. Morris, D. M., Taub, E., Mark, V. W. (2006). Constraint-induced movement therapy:

characterizing the intervention protocol. Europa medicophysica, 42(3), 257–268. https://pubmed.ncbi.nlm.nih.gov/17039224/

5. Stockbridge, M. D., Bunker, L. D., Hillis, A. E. (2022). Reversing the Ruin: Rehabilitation,

Recovery, and Restoration After Stroke. Current Neurology and Neuroscience Reports

22, 745–755. https://doi.org/10.1007/s11910-022-01231-5


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