By Gwendolyn Larsen, Kevin Berner, Annie Holland, Kathryn Kieran, Mirza Lugo-Neris, Tara Mansour, Alex Wolf, and Nara Gavin

Summary:
Stroke is a major global health concern, significantly impacting lives and healthcare systems, but innovations in rehabilitation techniques—from telehealth to advanced neurotechnology—are enhancing recovery outcomes for stroke survivors.

Key Takeaways:

  1. Comprehensive Rehabilitation: Stroke rehabilitation involves a multidisciplinary team to address diverse physical, cognitive, and emotional challenges, ultimately improving quality of life and independence.
  2. Technological Innovations: Emerging therapies, such as transcranial stimulation, vagus nerve stimulation, brain-computer interfaces, robot-assisted therapy, and virtual reality, are expanding treatment options and improving accessibility and personalization in stroke recovery.
  3. Person-Centered and Collaborative Care: A holistic, client-centered approach, emphasizing mental health and interprofessional collaboration, is central to enhancing patient outcomes and family support in stroke rehabilitation.

Featured image: Interprofessional collaboration on shared goals increases quality of care and improves outcomes for people with stroke.

According to the World Health Organization, 12.2 million people experience a stroke annually.1 It is the second leading cause of death and a major cause of long-term disability worldwide.1 The economic burden of stroke is significant, with estimates of over $53 billion per year in healthcare costs and lost productivity in the United States alone.2

After stroke, people can experience a variety of functional limitations. Depending on the area of the brain affected, impaired movement, balance, language, and cognition can emerge. Individuals can also develop anxiety, depression, personality changes, or impaired social skills. Stroke rehabilitation addresses these challenges by maximizing recovery, improving function, enhancing quality of life, and increasing participation. A multidisciplinary team of specialists—including but not limited to physical therapists, occupational therapists, speech-language pathologists, and mental health professionals—implement diverse treatment strategies to achieve these aims. 

Further Reading: Trends in Inpatient Stroke Rehabilitation

Research in stroke rehabilitation is expanding, providing evidence for the most effective care models and innovative technologies. These developments are making rehabilitation more client-centered, convenient, and effective, offering new hope for stroke survivors and their families. 

Examples of Innovative Approaches to Stroke Rehabilitation

Telehealth

Telehealth uses telecommunications technology to support geographically remote health services. Before the COVID-19 pandemic, there was growing support for telehealth to improve access to healthcare and rehabilitation. In 2016, the American Stroke Association recommended the use of telehealth to support those with communication impairments post-stroke where access to traditional services was limited.3 Mental health services such as Cognitive Behavioral Therapy provided via telehealth had been well established.4,5

The COVID-19 pandemic accelerated the use of telehealth services in 2020. The reduction in state and federal policy regulations and the expansion of reimbursement for services facilitated rapid implementation. A survey of physical therapists in 2021 found 48% of providers were offering telehealth compared to 2% pre-pandemic.6 Similar spikes were seen in other rehabilitation specialties. 

Telehealth interventions have proved to be effective as an alternative or complement to conventional care after stroke. Positive treatment outcomes have been related to motor function, activities of daily living, cognition, and communication.7,8 Telehealth is more widely available than ever, increasing accessibility to rehabilitation services. Additional research including larger clinical trials will help identify the most effective treatment approaches to use in this delivery model.

Person-centered Care

Person-centered care is a model that is collaborative, integrative, and responsive to an individual’s goals, preferences, and values.9 It considers physical and emotional needs. A third of individuals post-stroke experience depression, and anxiety strikes about 20%.10 Surveys and interviews with patients and families document prominent feelings of frustration, worry, and stress.10 The best stroke rehabilitation programs incorporate holistic, wrap-around care that includes emotional health check-ins, support for caregivers, peer support, and case management as part of treatment planning. This approach can significantly impact outcomes and improve independence, participation, and quality of life for persons with stroke while reducing demands on caregivers.10,11

An outgrowth of movements in healthcare centering and respecting patient experiences and voices has led to attempts to involve patients in developing interventions, sometimes called co-creation, or participatory design. In co-creative models, people with stroke and care providers work together to review plans for new or updated services. Most are community-based and focus on rehabilitation activities like socialization, communication, or physical activity.12

Interprofessional Collaboration

Interprofessional collaboration refers to providers of different fields working together to support the holistic needs of persons recovering from stroke. Members of interprofessional teams may include physicians, nurses, physical therapists, occupational therapists, speech-language pathologists, social workers, and mental health providers, among others. 

Successful professional collaboration requires sharing a mission, values, goals, and working environments with an effective system of communication. When members of interprofessional teams have a clear identity within the team and a sense of support, respect, and value, they can better serve the needs of their patients.13 In turn, healthcare quality for patients is improved, resulting in increased individual and family involvement in the care plan, adherence to medications, and improved quality of life.13

Technological Advances in Stroke Rehabilitation

Transcranial Magnetic, Alternating, and Direct Current Stimulation

Transcranial electrical treatments are an emerging area in post-stroke assessment and rehabilitation. These non-invasive technologies involve placing magnets or electrical devices on the scalp. Transcranial magnetic stimulation (TMS) uses magnetic fields to stimulate nerve cells in the brain. TMS is under investigation for a variety of indications but is already approved to treat depression, obsessive-compulsive disorder, and migraines and as an intervention for smoking cessation. 

man using a robot-assisted device on his arm to cut a cucumber after a stroke
Robot-assisted devices are an effective tool to enhance motor recovery and function after stroke.

TMS shows promise in both predicting and treating motor function recovery after stroke. Repetitive TMS (rTMS) is a treatment adjunct to modify the excitability of the motor cortex in preparation for rehabilitation, but studies in the acute and sub-acute stages after stroke are limited, and gains in motor function are modest.14 Other transcranial electrical treatments (tES), such as transcranial alternating current (tACS) and transcranial direct current (tDCS) are still in the nascent research phase but potentially may facilitate motor, communication, and psychiatric recovery if the correct dose and location are discovered. Further investigation is necessary before these techniques can be routine for any new indications in clinical care.15

Vagus Nerve Stimulation

Vagus nerve stimulation (VNS) technology is an approach to stroke rehabilitation that has gained attention recently. Both invasive and non-invasive techniques have been developed that target the vagus nerve in the neck region or ear using a small electrical device. VNS paired with motor rehabilitation has demonstrated beneficial effects on arm function and dysphagia in stroke survivors.16,17 Research has also shown that when paired with cognitive training, VNS results in improvements in memory and attention, although effects on cognition for people with stroke require further study.16 Overall, VNS technology shows promise as a complementary approach to stroke rehabilitation and is well-tolerated by patients. However, more research is needed to fully understand its effects and determine optimal parameters for stimulation. 

Brain-Computer Interfaces

Brain-computer interfaces (BCIs) work by detecting and interpreting neural signals from the brain and translating this intention into digital output signals that can control a computer or external device.18 BCIs can potentially improve rehabilitation outcomes by promoting neuroplastic reorganization or providing alternative control of movement methods.18,19 Invasive and non-invasive techniques have been developed.20

In the context of stroke rehabilitation, BCIs can be used to facilitate motor recovery when paired with training by providing real-time visual or auditory feedback and physical assistance as needed.19,21 In a pilot study of 4 persons with stroke,21 researchers used electroencephalogram signals to provide visual feedback along with sensory and physical feedback through neuromuscular electrical stimulation to the affected upper extremity. BCI signals may also be manipulated to operate compensatory aids, robotic exoskeletons, prostheses,22,23,24 and computer cursors for device operation or communication outputs.19,24 Existing literature highlights the rapidly advancing nature of BCIs, but few published studies have consistently examined functional or client-centered outcomes of stroke survivors.18,19,22,23 While the technology is still in the early stages of development, continued research and development into BCIs could lead to more effective and accessible rehabilitation options for those with disability from stroke. 

Robot-Assisted Therapy

Robot-assisted therapy is a rapidly growing field in stroke rehabilitation. These devices assist with movement of the upper or lower extremity where voluntary movement is impaired. Robot-assisted therapy has been shown to improve motor function, upper limb function, activities of daily living, gait, and balance in some persons with stroke.25,26,27 Robot-assisted therapy can reduce the manual burden on therapists and can be programmed to adjust the intensity and difficulty of the therapy based on the patient’s progress and performance. Additional advantages of this non-invasive approach are that these devices have potential to introduce game-like elements, making therapy more engaging and motivating. The ability to use some devices independently in the home makes therapy more accessible and convenient, too. Artificial intelligence is being integrated into robot-assisted therapy to analyze patient data, predict patient progress, and adjust therapy accordingly.

Virtual Reality 

Virtual reality (VR) therapy is an evolving modality for stroke rehabilitation that utilizes virtual environments to simulate real-life scenarios. VR technology enables individuals to practice activities in a safe and controlled environment with real-time feedback and allows therapists to provide more personalized and effective treatments. Perception of realism through VR devices varies on a spectrum from non-immersive, as with a video game console, to fully immersive such as a VR head mount display. 

Using VR to Enhance Patient Engagement and Outcomes

VR therapy has demonstrated positive effects on motor function, balance, gait, and daily function in persons with stroke28 and potentially some aspects of cognition,29 although use of it to address communication and mental health has not shown a benefit.28,29,30 Despite the promising results of VR therapy in stroke rehabilitation, some challenges need to be addressed. The cost of VR technology can be prohibitive for some clinics and hospitals, and not all patients may be suitable candidates for VR therapy due to visual or significant cognitive impairments. As the technology continues to evolve and become more affordable, VR may become a more widely used and effective tool in rehabilitating persons with stroke. 

Conclusion

Stroke rehabilitation is a critical component of care for stroke survivors that improves function and quality of life. It is a complex and multidisciplinary process involving various therapies and interventions. Innovative approaches like telerehabilitation, client-centered care, and interprofessional collaboration have shown promise in improving outcomes for stroke survivors. Recent technological advances, such as transcranial magnetic and electric stimulation, vagus nerve stimulation, brain-computer interfaces, robot-assisted therapy, and virtual reality paired with active rehabilitation offer new hope for stroke survivors and their families. Future research will continue to build on these advancements, making rehabilitation interventions more accessible, affordable, and effective, improving the lives of those affected by stroke. 

This article was an interprofessional collaboration of faculty at the MGH Institute of Health Professions in Boston, Mass., with support from Tedy’s Team Center of Excellence in Stroke Recovery. The authors represent diverse experience and expertise in stroke rehabilitation including clinical, research, and technology. 

Gwendolyn Larsen, PT, DPT, is an Instructor in the Department of Physical Therapy; Kevin Berner, OTD, OTR, ATP is an Assistant Professor in the Department of Occupational Therapy; Annie Holland, MS, CCC-SLP, is an Instructor and Clinical Supervisor in the Department of Communication Sciences and Disorders; Kathryn Kieran, MS, PMHNP-BC, is an Instructor in the School of Nursing; Mirza Lugo-Neris, PhD, CCC-SLP, is an Assistant Professor in the Department of Communication Sciences and Disorders; Tara Mansour, OT, OTD, MS, OTR, is an Assistant Professor and Academic Fieldwork Coordinator in the Occupational Therapy Department; Alex Wolf, DNP, APRN, ACHPN, is an Assistant Professor in the School of Nursing; and Nara Gavini, PhD, MPhil, is a Professor and Associate Provost for Research. 

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