Treatment for Chronic Stroke

Secondary Stroke Prevention

The American Heart Association recommends long-term single antiplatelet therapy with either aspirin 81 mg daily or clopidogrel 75 mg daily for secondary prevention in chronic stroke patients 1
Target blood pressure should be <130/80 mmHg, and initiate angiotensin-converting enzyme inhibitors combined with a thiazide diuretic as first-line therapy 1
Target LDL-cholesterol <1.8 mmol/L (70 mg/dL) for all chronic stroke patients, particularly those with atherosclerotic disease, and prescribe atorvastatin 80 mg daily for patients with LDL >2.5 mmol/L (100 mg/dL) without proven cardioembolic mechanism 1
Smoking cessation with counseling plus pharmacotherapy (nicotine replacement, bupropion, or varenicline) is mandatory 1
Prescribe low/moderate-intensity aerobic activity for 10 minutes, 4 days per week, or vigorous aerobic activity for 20 minutes twice weekly 1
Weight loss is required for overweight/obese patients (BMI assessment at every visit) 1
Target HbA1c ≤7% for diabetic patients using glucose-lowering agents with demonstrated vascular benefit 1

Chronic stroke patients should receive intensive, task-specific therapy in a specialized stroke rehabilitation unit with an interdisciplinary team (physicians, nurses, physiotherapists, occupational therapists, speech-language therapists, social workers, dieticians) 1
For chronic aphasia (>6 months post-stroke), provide at least 10 hours per week of therapist-led individual or group therapy for 3 weeks, plus 5+ hours per week of self-managed training 2
Rehabilitation should maximize scheduled task-specific therapy to meet optimal recovery and tolerability 1
For chronic aphasia, speech-language therapy improves functional communication, reading comprehension, expressive language, and written language 2
Include communication partner training for family members and caregivers to improve functional communication outcomes 2
Group therapy and conversation groups may supplement individual therapy intensity during hospitalization and serve as continuing therapy post-discharge 2

First-line treatment: antispastic positioning, range of motion exercises, stretching, splinting, and serial casting performed several times daily 3
Second-line pharmacotherapy: For spasticity causing pain, poor skin hygiene, or decreased function, prescribe tizanidine, dantrolene, or oral baclofen (starting 5-10 mg/day, titrating to 30-80 mg/day divided into 3-4 doses) 3
Avoid benzodiazepines (diazepam) during stroke recovery due to deleterious effects on recovery and sedation 4
For focal spasticity: Botulinum toxin injections are more effective than oral baclofen and should be used as first-line pharmacological intervention 5

Treadmill training with partial body weight support may be used as an adjunct to conventional therapy for patients with mild-to-moderate gait dysfunction 3
Commence mobilization within 48 hours of stroke onset unless contraindicated, but avoid intensive out-of-bed activities within the first 24 hours 1

Implement person-centered, collaborative goal setting with patients and families, clearly documented and regularly reviewed, including around transitions of care 1
Provide formal and informal patient, family, and caregiver education throughout the rehabilitation process 1
Reassess goals and plans at appropriate intervals over time, particularly for patients with communication disorders 2