Stroke Rehabilitation Protocol — Acute • Subacute • Chronic (3-Stage Model)

Complete, exam-ready and clinic-ready stroke rehabilitation protocol using the 3-stage model: Acute (0–72 hrs) • Subacute (3 days–3 months) • Chronic (>3 months). Includes assessments, treatment goals, evidence-based interventions, flowcharts, mnemonics, interactive stage-selector tool, MCQs and references — ready to paste into your Blogger post.

Overview & Purpose

Rehabilitation after stroke aims to reduce complications, restore function, promote independence and improve quality of life. Timing matters: interventions differ by stage because neurological recovery (neuroplasticity) is time-dependent.

Stroke Stages (3-Stage Model)

Acute

0–72 hours — ICU/ward. Stabilize, prevent complications, early mobilization if safe.

Subacute

3 days – 3 months — rehabilitation phase with high neuroplastic potential; intensive task training.

Chronic

> 3 months — long-term functional recovery, community reintegration, secondary prevention.

Stage-Specific Rehab Goals (Quick Table)

Stage	Time window	Main Goals
Acute	0–72 hours	Medical stabilization, airway/respiratory care, prevent DVT/pressure sores, maintain ROM, early safe mobilization, family education
Subacute	3 days – 3 months	Maximize recovery via task-specific training, gait re-education, ADL training, spasticity management, cognitive & language rehab
Chronic	>3 months	Improve endurance/strength, community participation, advanced gait/upper limb training, vocational rehab, secondary prevention

Assessment Checklist (Start Here)

Use this checklist on first contact and at each stage:

• Vitals, consciousness (GCS/NIHSS), medical stability
• Neurological exam: cranial nerves, tone, reflexes, sensation
• Motor: MMT, synergies (Brunnstrom), Fugl-Meyer motor score
• Balance & mobility: Berg Balance Scale, TUG, 10-m walk test, 6MWT
• ADL & function: Barthel Index, FIM
• Cognition & communication: MOCA/MMSE, speech therapist input
• Swallowing: bedside swallow screen, speech pathology
• Respiratory: chest auscultation, cough effectiveness, peak cough flow if available
• Skin check, DVT risk (Wells/GCS for prophylaxis)

Fast Evidence Scales (use in charting)

Scale	Use
NIHSS	Initial stroke severity (neurology)
Fugl-Meyer	Upper & lower limb impairment quantification
Berg Balance Scale	Static & dynamic balance
10-meter walk test	Gait speed (functional ambulation)
Barthel Index / FIM	ADL independence

Acute Stage Protocol (0–72 hours)

Primary focus: medical stabilization, prevent secondary complications, early safe mobility when medically permitted.

Precautions & Red Flags (Acute)

• Unstable vitals, fluctuating consciousness
• Active hemorrhage, uncontrolled BP (follow stroke unit protocol)
• Recent thrombectomy/cranial surgery — follow neurosurgery orders
• Severe respiratory compromise — prioritize airway & suction

Acute Interventions (ordered by priority)

1. Medical coordination: work with stroke team — BP, anticoagulation, glucose control
2. Positioning: head-of-bed 30°, neutral alignment, turn schedule every 2 hrs to prevent pressure injuries
3. Respiratory care: breathing exercises, assisted cough training, chest physiotherapy if secretion load
4. Early mobilization: sitting balance at edge of bed, transfer to chair (if safe). Use NIHSS/medical clearance — start ONLY when stable.
5. ROM & contracture prevention: gentle PROM, splinting for hand/ankle in functional position
6. DVT prophylaxis: ankle pumps, compression (as per protocol), early mobilization
7. Swallow & communication: bedside swallow screen, speech therapy referral before oral intake
8. Family education: positioning, skin checks, communication changes

Acute mobility rule: early sitting & upright exposure improves orthostatic tolerance and reduces ICU complications — but only with medical clearance.

Acute: Quick flow (visual)

0–24 hrs

Stabilize airway, CT/CTA, thrombolysis decision

24–48 hrs

Respiratory care, begin sitting if allowed, PROM, skin protection

48–72 hrs

Functional transfers, early assessment (NIHSS, Fugl-Meyer), plan rehab

Subacute Stage Protocol (3 days — 3 months)

Primary focus: maximize neurological recovery using neuroplasticity principles — intensive task-specific, repetitive, progressive practice.

Key principles (Subacute)

• High-repetition task-specific training (principle of use-dependent plasticity)
• Early, graded weight-bearing & locomotor training
• Active participation & problem-solving — promote motor learning
• Intensity — frequency and dose matter (as tolerated medically)

Subacute Interventions — Upper Limb

• Task-oriented training (reach, grasp, release)
• Constraint-Induced Movement Therapy (CIMT) — if eligible (good cognition, some voluntary wrist/finger extension)
• Mirror therapy, motor imagery, mental practice
• Functional electrical stimulation (FES) for wrist/finger extensors
• Spasticity management: positioning, stretching, splints, consider botulinum toxin if focal spasticity limiting function

Subacute Interventions — Lower Limb & Gait

• Task practice: sit-to-stand, step training, obstacle negotiation
• BWSTT (body weight-supported treadmill training) or overground gait training
• Gait speed training (10-m walk), progressive resistance for hip/knee/ankle
• Balance training: reactive, anticipatory, sensory reweighting
• Orthoses as needed (AFO) to improve gait biomechanics

Subacute Interventions — Other Domains

• Cardiovascular training: start low intensity and progress (monitor HR, BP)
• Cognitive & perceptual training: neglect rehab, dual tasking
• Speech & swallowing therapy continued
• ADL training: graded independence with adaptive equipment

Dose guidance (subacute): Aim for multiple daily practice sessions (20–60 minutes each), target high repetitions (hundreds of task repetitions daily across therapy & practice time), adapted to endurance and medical status.

Subacute: Typical weekly program (example)

Day	Morning	Afternoon	Evening/home
Mon–Fri	Gait training/BWSTT 30 min + balance 15 min	Upper limb task practice 30 min + FES 20 min	Home program: 30 min repetition & ADL training
Sat	Functional mobility, transfers 45 min	Family education & home setup 30 min	Rest/low intensity
Sun	Rest / gentle mobility	Telerehab check-in	Home practice

Chronic Stage Protocol (> 3 months)

Primary focus: long-term gains, compensatory strategies, community reintegration, improving endurance, return to work & preventing secondary complications.

Chronic interventions

• Advanced gait training: treadmill with incline, overground speed and endurance training
• Progressive resistance training for major muscle groups (guided to avoid overuse)
• Task-specific practice for complex activities (stairs, community mobility)
• Botulinum toxin + casting for focal spasticity affecting function
• Orthoses, adaptive devices, home & workplace modification
• Vocational rehab, psychosocial support

Chronic: Monitoring & measurable outcomes

• Reassess every 3 months: 10-m walk, 6MWT, Berg, FIM, goal attainment scaling
• Use telerehabilitation for maintenance programs
• Address pain syndromes (shoulder subluxation, spasticity pain)

Contraindications & Safety Across All Stages

• No aggressive passive stretching into pain in hyperacute hemorrhagic stroke without clearance
• Avoid high-intensity aerobic training if unstable angina, uncontrolled BP, or arrhythmia
• Respect post-thrombolysis and post-procedure weight bearing / activity limits per stroke unit
• Monitor for signs of overuse fatigue; schedule adequate rest

Patient stabilized → Decide Rehab Stage --------------------------------------- • Acute Stage (0–72 hrs) ├─ Focus: Safety first ├─ ROM + Positioning ├─ Respiratory care └─ Early sitting only if medically cleared • Subacute Stage (3 days – 3 months) ├─ Intensive task-specific training ├─ Gait + Balance training ├─ Upper limb rehab (CIMT / Mirror / FES) └─ Spasticity management • Chronic Stage (> 3 months) ├─ Progressive strengthening ├─ Advanced gait + endurance training ├─ Community reintegration └─ Vocational rehab & long-term follow-up

Mnemonics & Quick Memory Aids

“S.T.A.R.T.” for Subacute Rehab

• S — Specific, task-oriented practice
• T — Timely, high repetition
• A — Arousal & attention training (cognitive)
• R — Repetition with variability
• T — Transfer to ADL & community

“A.R.M.S.” — Acute priorities

• A — Airway & breathing
• R — Reposition & skin care
• M — Monitor vitals & meds
• S — Safe early sit/mobilize (if cleared)

Interactive Tool — Stage Identifier & Rehab Plan

Tick items that describe the patient (based on time since stroke and clinical status). Click Identify Stage & Suggest Plan.

Time since stroke: 0–72 hours (acute)
Time since stroke: 3 days – 3 months (subacute)
Time since stroke: >3 months (chronic)

Medically stable (no active bleeding, controlled BP)
Able to sit with assistance
Some voluntary movement in affected limb
Respiratory status OK (no ventilator)

Clinical Pathways & Red Flags

• Any sudden deterioration in consciousness, new focal deficit, severe headache or seizure → urgent medical review / re-imaging.
• Post-thrombolysis: only mobilize per stroke unit protocol (often after 24 hours if stable).
• Persistent fever, rising WBC or chest signs → treat infection before intensive rehab.

Measuring Progress & Discharge Criteria

• Improvement in gait speed (10-m walk), increase in 6MWT distance
• Increase in Barthel Index / FIM score and independence in key ADLs
• Achieve safe transfers and community mobility with minimal assistance
• Home modifications and caregiver training completed

10 Practice MCQs (Stroke Rehab)

Q1. In the acute stage (0–72 hrs), the FIRST physiotherapy priority is:

Answer: A) Medical stabilization and prevention of complications.

Q2. The subacute stage best uses which principle for motor recovery?

Answer: B) Task-specific high-repetition practice.

Q3. Which intervention is contraindicated in an unstable acute stroke patient?

Answer: B) Intensive treadmill training without medical clearance.

Q4. Best measure for community ambulation capacity is:

Answer: B) 6-minute walk test.

Q5. Constraint-Induced Movement Therapy (CIMT) is most appropriate when:

Answer: A) Some voluntary wrist and finger extension (eligibility criteria).

Q6. Which is an early sign that a patient is ready for standing/gait training?

Answer: B) Medically stable and able to sit unsupported.

Q7. Which spasticity treatment is commonly used in subacute stroke to allow functional use?

Answer: A) Botulinum toxin injection for focal spasticity + therapy.

Q8. Best way to increase walking speed in subacute stroke:

Answer: B) Repetitive stepping practice at target speeds.

Q9. When discharging from inpatient rehab, which outcome is most important?

Answer: B) Safe independence in transfers & ADLs.

Q10. Long-term community reintegration after stroke best includes:

Answer: A) Vocational rehab, mobility training & psychosocial support.

Visual Aids & Exercise Examples

Simple progression: Sit → Stand → Step → Walk

  Example progression (session):
    1) Seated balance (2 mins) → 2) Sit-to-stand assisted (10 reps) →
    3) Static standing weight shifts (2 mins) → 4) Marching on spot (20 steps) →
    5) Overground stepping (10 m x 4)
  

Example exercise diagrams (text)

  A) Seated weight shift:
     - Patient sits on edge, shifts weight to affected side for 10 sec x 10 reps.
  B) Sit-to-stand progression:
     - Use armrests → hands on knees → hands on lap → no arms; aim 10 reps as tolerated.
  C) Repeated reach & grasp:
     - 10 reaches to shelf at shoulder height, pick object, return; repeat 5 sets.
  

FAQs — Quick Answers for Students

Q: When should CIMT be started?

A: Usually in the subacute phase when the patient has at least some active wrist and finger extension, good cognition and tolerance for intensive therapy. Always check local protocols and patient tolerance.

Q: How often should subacute patients train their affected limb?

A: High repetition — multiple daily practice sessions (cumulatively many hundreds of repetitions per day across tasks) is recommended where feasible and safe.

Q: Is early mobilization always good?

A: Early mobilization has benefits but must be medically screened: unstable vitals, intracranial pressure issues, or immediate post-thrombolysis restrictions override early mobilization.

References (Select, Credible)

• Bernhardt J, et al. (2015). Early mobilization after stroke: time for action. Lancet.
• Langhorne P, et al. (2011). Early supported discharge services for stroke patients. Stroke.
• Winstein CJ, et al. (2016). Guidelines for adult stroke rehabilitation and recovery: A guideline from the AHA/ASA. Stroke.
• Dobkin BH. (2005). Progressive staging of motor recovery after stroke. Neurorehabilitation and Neural Repair.
• O’Sullivan SB, Schmitz TJ. (2019). Physical Rehabilitation (7th ed.). F.A. Davis.

Want this exported as a printable one-page PDF, a step-by-step clinician checklist (printable), or a separate MCQ bank file? Reply which format and I’ll generate it.