Outpatient rehabilitation of chronic neurologic conditions

General Neurology

Updated 11.14.2023
Released 02.27.2019
Expires For CME 11.14.2026

Outpatient rehabilitation of chronic neurologic conditions

Authors: Jonathan Tiu MD, Florian P Thomas MD MA PhD MS

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Editor: Peter J Koehler MD PhD

Outpatient rehabilitation of chronic neurologic conditions

In This Article

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Introduction

Overview

Rehabilitation refers to a broad set of practices focused on maximizing function and minimizing disability after health challenges. For the clinician, rehabilitation is distinct from, but overlaps with, disease prevention, disease-modifying treatment, and palliative care. A large component of rehabilitation is therapy, which most commonly refers to physical therapy (physiotherapy), occupational therapy, and speech therapy (speech and language pathology). A therapeutic alliance and effective team communication between members of the rehabilitation team are core ingredients to successful outcomes. Neurologic therapy can aim to restore nervous system impairments, teach patients compensatory behaviors using unimpaired body systems or assistive technology, increase cardiovascular capacity, or help patients reintegrate into their community. Compared to measuring outcomes with medications or elective procedures, measuring the efficacy of neurologic therapy has historically been a challenge. However, rigorous study design and an increasingly refined understanding of the nervous system has yielded a growing body of high-quality data on rehabilitation outcomes for neurologic conditions.

Key points

	• Rehabilitation aims to maximize independence and decrease disability in any neurologic disease.
	• Therapy that restores a neurologic impairment is distinct from therapy for learning safe compensatory strategies and exercise to build cardiovascular capacity.
	• Task-specific exercise is the basic unit of restorative therapy, which can be enhanced with priming or augmenting tools.
	• Clinicians should exercise a low threshold to refer patients to outpatient rehabilitation services.
	• Formal evidence for rehabilitation benefits is growing; outcomes in Parkinson disease, stroke, and other neurologic conditions are outlined in this article.

Historical note and terminology

Rehabilitation is defined by the World Health Organization (WHO) as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment” (83). From the perspective of a neurologist, rehabilitation can be seen as a form of treatment aimed at function that is distinct from prevention of disease, disease-modifying therapy, or palliative care. Under this lens, administering levodopa for reducing motor symptoms of Parkinson disease is a common neurologic rehabilitation intervention. There is naturally overlap between the above treatment goals. For example, a medication used to prevent migraines can not only reduce the suffering of the patient (palliative care) but also mitigate participation restrictions from lost work or school productivity (rehabilitation). Similarly, post-stroke aerobic exercise can be used to increase activity tolerance but can also reduce the risk of stroke recurrence by modifying vascular risk factors (09). This article will focus on outpatient rehabilitation therapy.

The WHO International Classification of Functioning, Disability and Health (ICF) framework was endorsed by all WHO Member States in 2001 as a standard international platform to characterize and measure disability (34; 83). It is beneficial for the neurologic provider to be familiar with the ICF framework, which provides a common language for members of a rehabilitation team to efficiently communicate and work towards shared rehabilitation goals. Using this framework, an individual with a health condition (eg, stroke) may experience one or more bodily impairments due to the condition (eg, hemiplegia). This may translate into limitations in the individual’s ability to move or to care for him or herself. At the highest level of disability, such limitations translate into restrictions in participation with school, work, or their community (34).

As a clinical specialty, dedicated Neurorehabilitation physician training pathways exist through both Neurology and Physical Medicine & Rehabilitation, among others (19). Programs are also available for specialization in brain injury or spinal cord injury. However, specialty training is certainly not required to prescribe outpatient therapy or to be an effective member of the rehabilitation team.

The rehabilitation team places the patient at the center. Outpatient settings for therapy include traditional outpatient therapy centers, interprofessional outpatient day programs, and home health services. Emerging evidence supports sustained benefits of intensive outpatient rehabilitation for conditions such as traumatic brain injury (17). Three members of the rehabilitation team are particularly relevant to the outpatient neurologist: physical therapists, occupational therapists, and speech therapists (speech and language pathologists). The scope of each of the three primary therapy disciplines is not always clearly divided, and transdisciplinary treatment (ie, treatment overlap) may occur. Their general scopes are summarized as follows.

Physical therapy. The aim of physical therapy is to improve “mobility-related activity,” a term that can refer to transfers, manual activities, posture, balance, and gait (60). Exercise training is a core strategy used by physical therapists in the treatment of neurologic disease. Exercise can be used to restore neurologic impairments via task-specific practice or to improve conditioning and increase activity tolerance. Exercise may include resistance training, aerobic activity, and balance training (60). Active and passive stretching may also be incorporated into the exercise routine. Often, an individualized home exercise program can be provided to a patient for ongoing practice at home.

Safety is paramount in physical therapy, and restrictions in activity, range of motion, or weight bearing are important for the clinician to define. Unsafe exercises that can result in falls, injuries, or delays in wound healing should be avoided.

Physical therapists can assist with the selection and customization of mobility-related assistive technology devices, also referred to as mobility products (53). These range from walking aids, such as canes and walkers, to manual or powered wheelchairs or prosthetics. Physical therapists may also help fit patients for orthotics, such as ankle-foot orthoses. Physical therapists may work in conjunction with an Assistive Technology Professional (ATP) or a Certified Prosthetist/Orthotist (CPO) to aid in device selection.

Occupational therapy. Patients with chronic neurologic impairments are often unable to participate fully in domestic, work, or leisure activities. The focus of occupational therapy is to improve “self-management” and allow for engagement in activities at home and in the community (60).

The occupational therapist individualizes a patient’s goals and priorities in order to tailor treatment. Observation of the activity in the established environment allows the therapist to identify modifiable personal or environmental factors (72). Self-reported surveys are often used to determine functional capacity and to measure occupational therapy outcomes (20). Newer technology, such as actigraphy, in-home video game rehabilitation, or wearables, are being implemented to more accurately evaluate and to improve functional performance at home (20; 27).

An occupational therapist may use many compensatory strategies to improve a patient’s safety and efficiency during activity. These may include development and implementation of a structured routine, use of external cues such as calendars, and use of a simplified or stepwise approach to a particular activity (72). These strategies help a patient manage the stress that arises from time pressure, unexpected changes in environment, or fluctuations in function. The latter is particularly true in patients with Parkinson disease who experience fluctuations in motor control between medication doses (60).

Occupational therapists can provide guidance on environmental adaptation and use of assistive technology, such as sock aids; head mouse devices and environmental control units, eg, for patients with tetraplegia; or adaptive food utensils. Optimizing the home or work environment may entail eliminating trip hazards or rearranging or modifying furniture and lighting for optimal daily living (60). Additionally, an occupational therapist may help identify durable medical equipment to improve safety, such as grab bars and shower seats. Occupational therapists may perform driving evaluations, provide compensatory driving strategies, or evaluate for the use of adaptive driving devices (18).

Speech therapy or speech and language pathology. The goal of speech therapy is to address impairments of language, speech, cognition, and swallowing, which are common in many neurologic diseases.

A variety of speech therapy interventions have been developed and studied for the restoration of language impairment in patients with aphasia. Speech therapy for post-stroke aphasia may help improve functional communication, reading, writing, and expressive language (08). One specific example of speech therapy is intensive language-action therapy (ILAT), which is a form of therapy that focuses on constraint, embedded communication, and massed practice, which may benefit not only aphasia after stroke but also post-stroke depression (40; 07).

A speech therapist can also address motor speech disturbances, such as dysarthria or hypophonia. Oral motor exercises are a mainstay of treatment. Biofeedback, using audio playback or visual acoustic analysis, can be used to improve volume and prosody of speech (02). In the setting of speech apraxia, in which volitional control of speech is impaired, a speech therapist may employ use of automated tasks, such as counting or singing along with repetition of sounds or words (02). When motor speech disturbances limit effective oral communication, speech therapists may also evaluate patients for appropriateness and selection of augmentative and alternative communication (AAC) devices.

Speech therapists can guide safety of swallowing food by mouth in patients with dysphagia. Evaluation begins with an oral motor examination but may require specialized evaluation with a modified barium swallow study or a fiberoptic endoscopic evaluation of swallowing. Food and liquid consistency may be modified according to standardized levels, such as those identified in the International Dysphagia Diet Standardisation Committee (IDDSI) framework (13). Speech therapists can teach patients compensatory strategies, such as postural maneuvers, to improve swallowing safety (66). In many settings they evaluate patients together with dietitians.

Speech therapists are instrumental in cognitive remediation for many neurologic conditions, such as traumatic brain injury, stroke, or multiple sclerosis. Cognitive impairment and cognitive rehabilitation are also increasingly recognized in the care of epilepsy patients and in primary progressive aphasia (06; 80). In this, their competencies and work profiles overlap with those of neuropsychologists.

Clinical aspects

Description

Many neurologic conditions may be associated with chronic impairments, sudden-onset, subacute, or chronically progressive. Evidence for benefits for specific therapy interventions and technologies is accumulating (73). Conditions such as stroke, Alzheimer disease, Parkinson disease, cerebral palsy, and spinal cord injury have larger bodies of evidence investigating the effectiveness of rehabilitation, but support for rehabilitation for Huntington disease, functional neurologic disorder, and epilepsy is also mounting. Innovations in the delivery of rehabilitation have also grown, with the use tele-rehabilitation accelerated by the COVID-19 pandemic (75). In addition, evidence for the use of innovative treatment tools to enhance rehabilitation efficiency and outcomes is also increasing (73).

On the other hand, rehabilitation therapy is a finite resource, limited by therapist availability and subspecialty training, insurance or financial limitations, and access (including transportation and scheduling constraints) (67; 25). Many patients’ rehabilitation needs are frequently not met (67; 25; 61). Efficient utilization of therapy resources requires informed clinical decision making on behalf of the neurologist. However, navigating the literature on the multitude of interventions can be complex due to the complexity of the nervous system, the heterogeneity in therapy quality and quantity, and the difficulty in controlling for the randomness of daily life. Therefore, it can be helpful to take a top-down approach in identifying the goals of therapy.

Goals of rehabilitation therapy. Neurologic therapy can increase function via one or multiple goals or “mechanisms.” These include, but are not limited to, the following:

1. Restoration

2. Compensation

3. Increasing activity tolerance / decreasing symptoms

4. Assessment for assistive technology

5. Caregiver training

6. Community re-integration

Restoration. Restoration refers to the reduction of deficits of a specific bodily impairment caused by neurologic injury (39; 59). For instance, therapy might aim to restore upper extremity motor function after stroke. Restoration relies on neural plasticity (49), which occurs at all levels of the nervous system to varying degrees, although it is generally more active in the brain versus the spinal cord or peripheral nervous system (70). Restoration may occur spontaneously after injury as a result of reactive plasticity (39). In contrast, neurologic rehabilitation primarily operates via experience-dependent plasticity (39). Restorative therapy is achieved by mass practice or mass repetition of task-specific exercise that has salience for the individual (49). The mechanisms involved are complex and include long-term potentiation, axonal sprouting, remyelination, neuronal memory allocation, and network reorganization or vicariation (39). Restoration may also aim to reverse or prevent maladaptive plasticity where development of deleterious signaling patterns lead to a decrease of function. Synkinesis of the eye and lip after Bell palsy is an example of maladaptive plasticity; its risk may be minimized with early neuromuscular re-training (38).

The effective “dose” of task-specific exercise—the number of good quality repetitions that are required to maximize the restoration of a deficit—is not known. Nudo and colleagues determined in their seminal work that restoration of upper extremity impairment and measurable reorganization of primary motor cortex could be detected in a squirrel monkey stroke model, when animal subjects performed 600 repetitions of a pellet retrieval task per day (56). By contrast, in observed therapy sessions targeting upper extremity rehabilitation, task-specific exercise occurred in just 51% of sessions, with an average of 32 repetitions per session (41). New technologies seek to increase the volume of massed practice. Partially supervised tele-rehabilitation is being studied to increase the dose of task-specific exercise after stroke (22). Gamification and virtual reality provide immersive and engaging ways for patients to increase task-specific exercise (84). Robotic rehabilitation is promising for increasing practice volume--not just for sensorimotor impairments but also for cognitive impairment (28; 84).

Task-specific exercise can be enhanced to increase its efficiency using priming and augmenting tools. Priming tools increase the excitability of the central nervous system, preparing it for plasticity. The VNS-REHAB trial demonstrated that transcutaneous stimulation of the left vagus nerve during occupational therapy for chronic upper extremity motor stroke can significantly increase upper extremity function (16). Augmenting tools amplify the action of an exercise at the level of the peripheral nerve or muscle (59). A 2023 network meta-analysis comparing therapy interventions for upper extremity function after stroke found that, in the subacute phase of stroke, augmenting task-specific training with neuromuscular electrical stimulation (NMES) had the strongest evidence for an effect at the end of the intervention (74).

Compensation. When a severe impairment has limited potential for restoration, efforts can instead focus on compensation to complete functional tasks. For instance, a patient with a cervical spinal cord injury at C6 may have absent finger function, but there might be enough wrist extension to use a tenodesis splint to achieve an adaptive pincer grip (50). An individual with left hemiplegia might learn how to use the right arm to put on or take off a shirt. A patient with dysphagia and reduced laryngeal elevation might learn the “chin tuck” maneuver to improve swallowing function. This maneuver involves placing the chin closer to the chest, which can favorably modify pharyngeal dimensions to direct the bolus toward the pharynx and esophagus (66).

Compensation and restoration both rely on experience-dependent plasticity (39). A fine line may exist between restoration and compensation when compensatory mechanisms functionally support, or replace, components of an impairment. For instance, imaging correlates during motor rehabilitation for Parkinson disease support that both restorative and compensatory mechanisms participate in improving parameters of gait (05).

Increasing activity tolerance / decreasing symptoms. Immobility and deconditioning are common with neurologic disease and can result in reduced activity tolerance (48; 61). Evidence increasingly supports the benefit of exercise after neurologic injury for both functional and health outcomes. Progressive aerobic exercise in multiple sclerosis resulted in clinically relevant reductions in fatigue; however, there was a small effect on walking and no effect on quality of life (42). Supervised exercise was superior to unsupervised home exercise in improving fatigue, strength, and quality of life in chronic Guillain-Barré syndrome (69). In subacute stroke, body weight–supported treadmill training led to improved cardiovascular fitness and walking ability that endured at 1-year (48). Aerobic exercise in mild Parkinson disease could attenuate off-state motor signs (78). Exercise might be helpful as a priming agent for upper extremity restoration therapy (15).

Neurologic conditions can be associated with headache, pain, or vertigo and can be alleviated with therapy in certain cases. Therapy in the form of sub-symptom threshold aerobic exercise has emerged as a first-line treatment for sport-related concussion and may be more effective with a higher number of oculomotor or vestibular symptoms (14; 45). In children with cerebral palsy, range of motion is a cornerstone of treatment of spasticity, and interruption of therapy can result in worsened spasticity and decreased ankle joint range of motion (46). In migraine, four weekly sessions of manual therapy of the cervical spine using low velocity, high-amplitude movements were associated with decreased symptoms and increased quality of life, although headache specialists are generally cautious in accepting manual therapy as efficacy is difficult to prove (54).

Assessment for assistive technology. Therapists can help select individualized assistive technology to maximize patient function. Assistive technology refers to any product or device designed with the purpose of maintaining or improving an individual’s function or independence and ranges from communication devices to prosthetics and wheelchairs (31). Special training and certifications are available for assistive technology. For a patient with impaired vocal communication due to motor speech symptoms, his or her speech therapist might find that a particular AAC device with text-to-voice technology can allow the patient to effectively communicate with others (02). A physical or occupational therapist might fit a patient for any variety of mobility-related assistive technology devices or mobility aids, such as walkers or wheelchairs. A therapist specializing in wheelchair seating often works in collaboration with an assistive technology professional (ATP) for chair selection; furthermore, evaluation by an ATP is required by Medicare for all but the most basic power wheelchairs (53). Wheelchairs serve as an important means of functional independence for a variety of neurologic conditions, such as spinal cord injury (55; 53).

Care partner training. Neurologic impairments may result in dependence on other people to complete activities of daily living, such as grooming or toileting, or to achieve mobility through transfers and locomotion (82). However, formal professional caregiving can be costly. Members of a patient’s support system, such as family or friends, often provide informal caregiving. An important goal of therapy is educating informal care partners on how to assist a patient in a variety of functional tasks (82). Speech therapists can help care partners understand the communicative intent of patients with dementia (43). Physical therapists may instruct care partners on safe transfers that minimize the risk of injury. In some cases, and where there is adequate space in the patient’s residence, introducing transfer aids may be useful. Therapists may also instruct family members on how to administer caregiver-mediated exercise as a means of increasing exercise volume (79). Of note, there are opportunities for care partners to be certified for competency; in certain settings, eg, Veterans Administration, care partners may receive financial compensation as part of the patient’s health care entitlements.

Community re-integration. Often, rehabilitation can have a higher-level goal of maximizing community participation. Driving is a primary means of transportation for many individuals, and loss of individual driving ability after neurologic conditions such as stroke can result in reduced health outcomes and lowered rates of community integration (77). Driving rehabilitation can be pursued to assess readiness to return to driving, maximize safe driving behaviors, or evaluate for assistive technology, such as hand controls for those with paraplegia due to spinal cord injury (18). Vocational rehabilitation (or occupational rehabilitation) focuses on overcoming barriers to access or to return to employment, school, or other useful occupation (10). Outpatient and vocational rehabilitation are best tightly interlinked in order to anticipate and address patients’ functional needs before and after they become obstacles to return to work (76).

Delivering effective rehabilitation. Successful rehabilitation is person- and family-centered, goal-oriented with meaningful outcomes, inter-professional, evidence-based, satisfying, and safe (81). Effective rehabilitation begins with the formation of a rehabilitation contract between patients and the rehabilitation team (59). Rehabilitation team structures are often multidisciplinary or interdisciplinary (37). In multidisciplinary teams, disciplines work together but stay largely within their own boundaries (12). In inter- and trans-disciplinary teams, representatives of different disciplines and professions overlap in their competencies, view patients’ success as a shared responsibility, and harmonize links between them to form a coordinated whole (12; 37). Data support that using such team models can result in better outcomes for a range of neurologic conditions (35; 63; 68). Inter-professional collaboration can also be effective when delivered remotely. Patient satisfaction was high for a tele-rehabilitation program that provided physical therapy, occupational therapy, and speech therapy within the same tele-rehabilitation visit (75). Although interdisciplinary team models are thought to have certain benefits over multidisciplinary models, they rely on effective communication between team members, which can require additional resources. Barriers to implementation of an interdisciplinary team include differences in members’ individual priorities and vocabularies (63).

Behavioral health and rehabilitation. Identification of behavioral health conditions related to neurologic disease is vital to maximize rehabilitation success. Suboptimal health behavior, depression, and other psychiatric symptoms are prevalent in many neurologic diseases but are often underrecognized and undertreated (58). Fostering resilience is a main goal of both the acute inpatient and long-term outpatient rehabilitation. This responsibility is to be shared by care partners, therapists, physicians, psychologists, dietitians, nurses, social workers, and others. Post-stroke depression is associated with multiple negative outcomes, including higher functional decline (52). Psychological distress has been shown to have an inverse relationship to functional improvement in post-stroke patients (32). A trial determined that treatment of post-stroke depression with either citalopram or cognitive behavioral therapy along with rehabilitation showed greater benefit in depression scales than rehabilitation alone (26).

Indications

Providers should have a low threshold to refer patients to outpatient rehabilitation services. Rehabilitation can be beneficial regardless of disease progression, whether it be slowly progressive, as in Parkinson disease, monophasic as in spinal cord trauma, or episodic as in multiple sclerosis with relapses. In most cases, rehabilitation can be initiated regardless of disease stage. Stroke is an exception; the VECTORS and AVERT trials showed poorer outcomes with very early rehabilitation after stroke (21).

Contraindications

Patients with chronic neurologic syndromes may have comorbid health conditions that limit strenuous physical activity. Formal exercise testing may be indicated in patients with heart failure, exertional dyspnea, chest pain, or known arrhythmias to identify safe parameters of rehabilitation therapy (30).

Patients with Parkinson disease or spinal cord injury often develop autonomic instability. This can manifest as orthostatic hypotension leading to drops in blood pressure on sitting upright or standing. Symptomatic orthostatic hypotension may limit a patient’s ability to safely participate in exercise, and consultation with the patient’s provider may be required prior to initiation of rehabilitation services. Slow initiation of activities, abdominal binders, and medication adjustment may be helpful.

Pregnancy itself is not a contraindication to outpatient physical therapy though prior consultation with an obstetrician should be considered; in such instances, modification may be necessary (03).

A relative contraindication is cognitive impairment, which may reduce significant rehabilitation benefit due to impaired learning. On the other hand, and as an example, care partner education regarding fall risk may benefit the patient with dementia.

Outcomes

Outcomes of outpatient rehabilitation therapies on Parkinson disease, stroke, and select other neurologic conditions are presented here. This list is not comprehensive, and the curious reader is encouraged to reference other relevant MedLink articles.

Parkinson disease. Positive rehabilitation outcomes can be achieved in Parkinson disease, the fastest growing neurologic condition in the world (23). The main goal of treatment is maintenance of mobility and physical function. One trial found that aerobic exercise is associated with changes in functional connectivity, cognitive control, and reduced brain atrophy (36). A variety of therapy modalities and programs are in use for Parkinson disease; however, data on the comparative effectiveness and long-term durability of these programs remain limited (23). One such popular program is the Lee Silverman Voice Treatment (LSVT LOUD^®) program, which seeks to increase vocal loudness and may improve the immediate and long-term sound pressure of patients with Parkinson disease (62). In contrast, the Lee Silverman Voice Treatment BIG (LSVT BIG^®) program focuses on increasing the amplitude and speed of movement and was associated with improved motor function on part III of the Unified Parkinson's Disease Rating Scale (UPDRS) (51). Enjoyable group exercises, such as noncontact boxing (“Rock Steady Boxing”), table tennis (“Ping Pong Parkinson”), and dancing, highlight the potential benefits of social engagement for Parkinson disease. Formal evidence for their functional benefits remains limited, though noncontact boxing is associated with higher quality of life (44; 71).

External cues during exercise training are particularly helpful for patients with Parkinson disease who have trouble initiating voluntary movement (60). Such cues can be visual (such as floor markings, or lasers attached to assistive devices), auditory, or tactile. A review by Rutz and Benninger concluded that visual and auditory cuing as well as supervised slackline training were effective in reducing freezing of gait and that these interventions could be combined (65).

Stroke. Rates of functional recovery, whether due to restorative or compensatory mechanisms, are highest in the first 3 months after stroke (47). Stroke is considered chronic after 6 months (29). It is possible that timing of therapy may influence therapy outcomes, but this is incompletely understood. The C-PASS trial suggested a critical period of heightened plasticity in the subacute phase of stroke (days 60 to 90 post-stroke), when a high volume of additional task-specific exercise above standard therapy may have an enhanced benefit (21).

Emerging data challenge the convention that restoration potential is limited in the chronic phase, particularly when therapy is paired with effective priming and augmenting agents (39). A network meta-analysis determined that, augmentation of task-specific training with NMES in subacute upper extremity motor stroke had effect at the end of the intervention and improved activities of daily living at follow-up (mean period of 2.89 months) (74). The VNS-REHAB trial demonstrated that vagus nerve stimulation to prime upper extremity task-specific therapy in chronic stroke was associated with higher rates of improvements of upper extremity function versus therapy alone (16). The role of the contralesional hemisphere in plasticity after stroke is increasingly recognized. The IpsiHand brain-computer interface pairs noninvasive EEG with exoskeleton-based augmentation during upper extremity therapy to upregulate plasticity of the uninjured, ipsilesional hemisphere in chronic stroke (64).

A Cochrane review found that speech therapy for post-stroke aphasia could improve functional communication, reading, writing, and expressive language (08). One specific speech therapy modality is intensive language-action therapy (ILAT), which focuses on constraint, embedded communication, and massed practice; ILAT may improve not just aphasia after stroke, but also post-stroke depression (40; 07).

Several studies highlight benefits of exercise for risk factors for recurrent stroke (09). A meta-analysis determined that aerobic exercise after stroke impacts systolic blood pressure and fasting glucose; this effect was comparable to combined strength training and aerobic exercise (09). Outpatient rehabilitation alone or following inpatient rehabilitation reduced the risk of recurrent vascular events, readmission, and mortality for an average of 32 months (11).

Other neurologic conditions. A Cochrane review determined that rehabilitation in multiple sclerosis can improve functional outcomes, such as mobility and aerobic capacity, and quality of life (01). As per a systematic review on diabetic peripheral neuropathy, exercise therapy was associated with not only improved gait speed and daily physical activity level, but also reduced neuropathic pain (33). Aerobic exercise in slowly progressive neuromuscular diseases was determined to be safe in one meta-analysis and led to moderate post-intervention improvement of aerobic capacity; however, long-term efficacy was not clear (57).

The benefits of an interprofessional approach on outcomes in other neurologic disorders have also been demonstrated. A systematic review of therapy in Huntington disease demonstrated improved motor function, gait speed, and balance along with improved quality of life (24). Functional neurologic disorder can be successfully treated with a combination of rehabilitation therapy and behavioral health therapy (04).

References

01: Amatya B, Khan F, Galea M. Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2019;1(1):CD012732. PMID 30637728
02: Anderson M, Anzalone J, Holland L, Tracey E. Treatment of language, motor speech impairments, and dysphagia. Continuum (Minneap Minn) 2011;17(3):471-93. PMID 22810863
03: Anonymous. ACOG Committee Opinion No. 650: physical activity and exercise during pregnancy and the postpartum period. Obstet Gynecol 2015;126(6):e135-42. PMID 26595585
04: Aybek S, Perez DL. Diagnosis and management of functional neurological disorder. BMJ 2022;376:o64. PMID 35074803
05: Baglio F, Pirastru A, Bergsland N, Cazzoli M, Tavazzi E. Neuroplasticity mediated by motor rehabilitation in Parkinson's disease: a systematic review on structural and functional MRI markers. Rev Neurosci 2021;33(2):213-26. PMID 34461010
06: Baxendale S. Cognitive rehabilitation and prehabilitation in people with epilepsy. Epilepsy Behav 2020;106:107027. PMID 32208338
07: Berthier ML, Edelkraut L, López-González FJ, et al. Donepezil alone and combined with intensive language-action therapy on depression and apathy in chronic post-stroke aphasia: a feasibility study. Brain Lang 2023;236:105205. PMID 36495749
08: Brady MC, Kelly H, Godwin J, Enderby P, Campbell P. Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev 2016;2016(6):CD000425. PMID 27245310
09: Brouwer R, Wondergem R, Otten C, Pisters MF. Effect of aerobic training on vascular and metabolic risk factors for recurrent stroke: a meta-analysis. Disabil Rehabil 2021;43(15):2084-91. PMID 31794269
10: Canhete Pereira RM, Monteiro I. Vocational rehabilitation and return to work: integrative review. Rev Bras Med Trab 2020;17(3):441-55. PMID 32368678
11: Chang KC, Hung JW, Lee HC, et al. Rehabilitation Reduced readmission and mortality risks in patients with stroke or transient ischemic attack: a population-based study. Medical Care 2018;56(4):290-8. PMID 29419706
12: Choi BCK, Pak AWP. Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. Definitions, objectives, and evidence of effectiveness. Clin Invest Med 2006;29(6):351-64. PMID 17330451
13: Cichero JA, Lam P, Steele CM, et al. Development of international terminology and definitions for texture-modified foods and thickened fluids used in dysphagia management: the IDDSI framework. Dysphagia 2017;32(2):293-314. PMID 27913916
14: Corrado C, Willer BS, McPherson JI, et al. Adolescents with more oculomotor and vestibular signs of sport-related concussion benefit from aerobic exercise: an exploratory analysis. J Neurotrauma 2023;40(15-16):1718-29. PMID 36884297
15: da Silva ESM, Santos GL, Catai AM, et al. Effect of aerobic exercise prior to modified constraint-induced movement therapy outcomes in individuals with chronic hemiparesis: a study protocol for a randomized clinical trial. BMC Neurol 2019;19(1):196. PMID 31416436
16: Dawson J, Liu CY, Francisco GE, et al. Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-REHAB): a randomised, blinded, pivotal, device trial. Lancet 2021;397(10284):1545-53. PMID 33894832
17: DeGraba TJ, Williams K, Koffman R, et al. Efficacy of an interdisciplinary intensive outpatient program in treating combat-related traumatic brain injury and psychological health conditions. Front Neurol 2021;11:580182. PMID 33536993
18: Devos H, Akinwuntan AE, Gélinas I, George S, Nieuwboer A, Verheyden G. Shifting up a gear: considerations on assessment and rehabilitation of driving in people with neurological conditions. An extended editorial. Physiother Res Int 2012;17(3):125-31. PMID 22961912
19: Dimyan MA, Dobkin BH, Cohen LG. Emerging subspecialties: neurorehabilitation: training neurologists to retrain the brain. Neurology 2008;70(16):e52-4. PMID 18413581
20: Doman CA, Waddell KJ, Bailey RR, Moore JL, Lang CE. Changes in upper-extremity functional capacity and daily performance during outpatient occupational therapy for people with stroke. Am J Occup Ther 2016;70(3):1-11. PMID 27089298
21: Dromerick AW, Geed S, Barth J, et al. Critical period after stroke study (CPASS): a phase II clinical trial testing an optimal time for motor recovery after stroke in humans. Proc Natl Acad Sci U S A 2021;118(39):e2026676118. PMID 34544853
22: Edwards D, Kumar S, Brinkman L, et al. Telerehabilitation initiated early in post-stroke recovery: a feasibility study. Neurorehabil Neural Repair 2023;37:131-41. PMID 36876946
23: El Hayek M, Lobo Jofili Lopes JLM, LeLaurin JH, et al. Type, timing, frequency, and durability of outcome of physical therapy for Parkinson disease: a systematic review and meta-Analysis. JAMA Netw Open 2023;6(7):e2324860. PMID 37477916
24: Fritz NE, Rao AK, Kegelmeyer D, et al. Physical therapy and exercise interventions in Huntington's disease: a mixed methods systematic review. J Huntingtons Dis 2017;6(3):217-35. PMID 28968244
25: Frontera WR, DeGroote W, Ghaffar A; Health Policy & Systems Research for Rehabilitation Group. Importance of health policy and systems research for strengthening rehabilitation in health systems: a call to action to accelerate progress. Aust Occup Ther J 2023. [Epub ahead of print] PMID 37866888
26: Gao J, Lin M, Zhao J, Bi S, Ni Z, Shang X. Different interventions for post-ischaemic stroke depression in different time periods: a single-blind randomized controlled trial with stratification by time after stroke. Clin Rehabil 2017;31(1):71-81. PMID 26817808
27: Gauthier LV, Kane C, Borstad A, et al. Video Game Rehabilitation for outpatient stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis. BMC Neurol 2017;17(1):109. PMID 28595611
28: Gassert R, Dietz V. Rehabilitation robots for the treatment of sensorimotor deficits: a neurophysiological perspective. J Neuroeng Rehabil 2018;15(1):46.** PMID 29866106
29: Grefkes C, Fink GR. Recovery from stroke: current concepts and future perspectives. Neurol Res Pract 2020;2:17. PMID 33324923
30: Guazzi M, Arena R, Halle M, Piepoli MF, Myers J, Lavie CJ. 2016 focused update: clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations. Circulation 2016;133(24):e694-711. PMID 27143685
31: Howard J, Fisher Z, Kemp AH, Lindsay S, Tasker LH, Tree JJ. Exploring the barriers to using assistive technology for individuals with chronic conditions: a meta-synthesis review. Disabil Rehabil Assist Technol 2022;17(4):390-408. PMID 32663110
32: Huang HC, Chang CH, Hu CJ, et al. Time-varying effects of psychological distress on the functional recovery of stroke patients. Arch Phys Med Rehabil 2017;98(4):722-9. PMID 27744024
33: Jahantigh Akbari N, Hosseinifar M, Naimi SS, Mikaili S, Rahbar S. The efficacy of physiotherapy interventions in mitigating the symptoms and complications of diabetic peripheral neuropathy: a systematic review. J Diabetes Metab Disord 2020;19(2):1995-2004. PMID 33553048
34: Jette AM. Toward a common language for function, disability, and health. Phys Ther 2006;86(5):726-34. PMID 16649895
35: Jimenez XF, Aboussouan A, Johnson J. Functional neurological disorder responds favorably to interdisciplinary rehabilitation models. Psychosomatics 2019;60(6):556-62. PMID 31399207
36: Johansson ME, Cameron IGM, Van der Kolk NM, et al. Aerobic exercise alters brain function and structure in Parkinson's disease: a randomized controlled trial. Ann Neurol 2022;91(2):203-16. PMID 34951063
37: Karol RL. Team models in neurorehabilitation: structure, function, and culture change. NeuroRehabilitation 2014;34(4):655-69. PMID 24796442
38: Kim DR, Kim JH, Jung SH, et al. Neuromuscular retraining therapy for early stage severe Bell's palsy patients minimizes facial synkinesis. Clin Rehabil 2023;37(11):1510-20. PMID 36972474
39: Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res 2008;51(1):S225-39.** PMID 18230848
40: Kurland J, Stanek EJ 3rd, Stokes P, Li M, Andrianopoulos M. Intensive language action therapy in chronic aphasia: a randomized clinical trial examining guidance by constraint. Am J Speech Lang Pathol 2016;25(4S):S798-812. PMID 27997954
41: Lang CE, Macdonald JR, Reisman DS, et al. Observation of amounts of movement practice provided during stroke rehabilitation. Arch Phys Med Rehabil 2009;90(10):1692-8.** PMID 19801058
42: Langeskov-Christensen M, Hvid LG, Jensen HB, et al. Efficacy of high-intensity aerobic exercise on common multiple sclerosis symptoms. Acta Neurol Scand 2022;145(2):229-38. PMID 34687036
43: Lanzi AM, Ellison JM, Cohen ML. The "counseling+" roles of the speech-language pathologist serving older adults with mild cognitive impairment and dementia from Alzheimer's disease. Perspect ASHA Spec Interest Groups 2021;6(5):987-1002. PMID 35647292
44: Larson D, Yeh C, Rafferty M, Bega D. High satisfaction and improved quality of life with Rock Steady Boxing in Parkinson's disease: results of a large-scale survey. Disabil Rehabil 2022;44(20):6034-41. PMID 34498995
45: Leddy JJ, Burma JS, Toomey CM, et al. Rest and exercise early after sport-related concussion: a systematic review and meta-analysis. Br J Sports Med 2023;57(12):762-70. PMID 37316185
46: Lee H, Kim EK, Son DB, et al. The role of regular physical therapy on spasticity in children with cerebral palsy. Ann Rehabil Med 2019;43(3):289-96. PMID 31311250
47: Lee KB, Lim SH, Kim KH, et al. Six-month functional recovery of stroke patients: a multi-time-point study. Int J Rehabil Res 2015;38(2):173-80. PMID 25603539
48: Mackay-Lyons M, McDonald A, Matheson J, Eskes G, Klus MA. Dual effects of body-weight supported treadmill training on cardiovascular fitness and walking ability early after stroke: a randomized controlled trial. Neurorehabil Neural Repair 2013;27(7):644-53. PMID 23599221
49: Maier M, Ballester BR, Verschure PFMJ. Principles of neurorehabilitation after stroke based on motor learning and brain plasticity mechanisms. Front Syst Neurosci 2019;13:74.** PMID 31920570
50: Mateo S, Revol P, Fourtassi M, Rossetti Y, Collet C, Rode G. Kinematic characteristics of tenodesis grasp in C6 quadriplegia. Spinal Cord 2013;51(2):144-9. PMID 22945744
51: McDonnell MN, Rischbieth B, Schammer TT, Seaforth C, Shaw AJ, Phillips AC. Lee Silverman Voice Treatment (LSVT)-BIG to improve motor function in people with Parkinson's disease: a systematic review and meta-analysis. Clin Rehabil 2018;32(5):607-18. PMID 28980476
52: Medeiros GC, Roy D, Kontos N, Beach SR. Post-stroke depression: a 2020 updated review. Gen Hosp Psychiatry 2020;66:70-80. PMID 32717644
53: Michael E, Sytsma T, Cowan RE. A primary care provider's guide to wheelchair prescription for persons with spinal cord injury. Top Spinal Cord Inj Rehabil 2020;26(2):100-7. PMID 32760188
54: Munoz-Gomez E, Inglés M, Serra-Añó P, Espí-López GV. Effectiveness of a manual therapy protocol based on articulatory techniques in migraine patients. A randomized controlled trial. Musculoskelet Sci Pract 2021;54:102386. PMID 33989990
55: Nas K, Yazmalar L, Şah V, Aydın A, Öneş K. Rehabilitation of spinal cord injuries. World J Orthop 2015;6(1):8-16. PMID 25621206
56: Nudo RJ, Wise BM, SiFuentes F, Milliken GW. Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Science 1996;272(5269):1791-4. PMID 8650578
57: Oorschot S, Brehm MA, Daams J, Nollet F, Voorn EL. Efficacy of aerobic exercise on aerobic capacity in slowly progressive neuromuscular diseases: a systematic review and meta-analysis. Ann Phys Rehabil Med 2023;66(1):101637. PMID 35091111
58: Pagonabarraga J, Álamo C, Castellanos M, Díaz S, Manzano S. Depression in major neurodegenerative diseases and strokes: a critical review of similarities and differences among neurological disorders. Brain Sci 2023;13(2):318. PMID 36831861
59: Pomeroy V, Aglioti SM, Mark VW, et al. Neurological principles and rehabilitation of action disorders: rehabilitation interventions. Neurorehabil Neural Repair 2011;25(5 Suppl):33S-43S. PMID 21613536
60: Radder DLM, Sturkenboom IH, van Nimwegen M, Keus SH, Bloem BR, de Vries NM. Physical therapy and occupational therapy in Parkinson's disease. Int J Neurosci 2017;127(10):930-43. PMID 28007002
61: Raghavan P. A unified model for stroke recovery and rehabilitation: why now? Am J Phys Med Rehabil 2023;102(2S Suppl 1):S3-9. PMID 36634323
62: Ramig L, Halpern A, Spielman J, Fox C, Freeman K. Speech treatment in Parkinson's disease: randomized controlled trial (RCT). Mov Disord 2018;33(11):1777-91. PMID 30264896
63: Rodriguez Then FS, Jackson J, Ware C, et al. Interdisciplinary and transdisciplinary perspectives: on the road to a holistic approach to dementia prevention and care. J Alzheimers Dis Rep 2020;4(1):39-48. PMID 32206756
64: Rustamov N, Souders L, Sheehan L, Carter A, Leuthardt EC. IpsiHand brain-computer interface therapy induces broad upper extremity motor recovery in chronic stroke. medRxiv 2023. PMID 37693482
65: Rutz DG, Benninger DH. Physical therapy for freezing of gait and gait impairments in Parkinson disease: a systematic review. PM R 2020;12(11):1140-56. PMID 31994842
66: Saconato M, Chiari BM, Lederman HM, Gonçalves MI. Effectiveness of chin-tuck maneuver to facilitate swallowing in neurologic dysphagia. Int Arch Otorhinolaryngol 2016;20(1):13-7. PMID 26722339
67: Saumur TM, Gregor S, Xiong Y, Unger J. Quantifying the amount of physical rehabilitation received by individuals living with neurological conditions in the community: a scoping review. BMC Health Serv Res 2022;22(1):349. PMID 35296315
68: Seid AA, Demirdel E, Aychiluhm SB, Mohammed AA. Multidisciplinary rehabilitation for people with Parkinson's disease: a systematic review and meta-analysis. Parkinsons Dis 2022;2022:2355781. PMID 35265314
69: Shah N, Shrivastava M, Kumar S, Nagi RS. Supervised, individualised exercise reduces fatigue and improves strength and quality of life more than unsupervised home exercise in people with chronic Guillain-Barré syndrome: a randomised trial. J Physiother 2022;68(2):123-9. PMID 35396175
70: Shen J. Plasticity of the central nervous system involving peripheral nerve transfer. Neural Plast 2022;2022:5345269. PMID 35342394
71: Simpkins C, Yang F. Do dance style and intervention duration matter in improving balance among people with Parkinson's disease? A systematic review with meta-analysis. Parkinsonism Relat Disord 2023;106:105231. PMID 36470708
72: Sturkenboom IH, Graff MJ, Hendriks JC, et al. Efficacy of occupational therapy for patients with Parkinson's disease: a randomised controlled trial. Lancet Neurol 2014;13(6):557-66. PMID 24726066
73: Tamburin S, Smania N, Saltuari L, Hoemberg V, Sandrini G. Editorial: new advances in neurorehabilitation. Front Neurol 2019;10:1090. PMID 31681155
74: Tenberg S, Mueller S, Vogt L, et al. Comparative effectiveness of upper limb exercise interventions in individuals with stroke: a network meta-analysis. Stroke 2023;54(7):1839-53. PMID 37293804
75: Tenforde AS, Borgstrom H, Polich G, et al. Outpatient physical, occupational, and speech therapy synchronous telemedicine: a survey study of patient satisfaction with virtual visits during the COVID-19 pandemic. Am J Phys Med Rehabil 2020;99(11):977-81. PMID 32804713
76: Thomas FP, Goetz LL, Dixon T, et al. Optimizing medical care to facilitate and sustain employment after spinal cord injury. J Rehab Res Develop 2014;51(6):xi-xxii. PMID 25479192
77: Tiu J, Harmon AC, Stowe JD, et al. Feasibility and validity of a low-cost racing simulator in driving assessment after stroke. Geriatrics (Basel) 2020;5(2):35. PMID 32485824
78: van der Kolk NM, de Vries NM, Kessels RPC, et al. Effectiveness of home-based and remotely supervised aerobic exercise in Parkinson’s disease: a double-blind, randomised controlled trial. Lancet Neurol 2019;18(11):998-1008. PMID 31521532
79: Vloothuis JD, Mulder M, Veerbeek JM, et al. Caregiver-mediated exercises for improving outcomes after stroke. Cochrane Database Syst Rev 2016;12(12):CD011058. PMID 28002636
80: Volkmer A, Rogalski E, Henry M, et al. Speech and language therapy approaches to managing primary progressive aphasia. Pract Neurol 2020;20(2):154-61. PMID 31358572
81: Wallace SJ, Barnett A, Cheng BB, Lowe J, Campbell KL, Young AM. What is 'successful rehabilitation'? A multi-stakeholder nominal group technique study to inform rehabilitation outcome measurement. Clin Rehabil 2023;37(9):1248-59. PMID 36785902
82: Weir RL, Danilovich MK, Hoover DL. Systematic review of the effectiveness of caregiver training with functional mobility tasks for informal caregivers assisting patients with neurological diagnoses. Disabil Rehabil 2022;44(18):5082-9. PMID 34167399
83: World Health Organization. Rehabilitation. Available at: https://www.who.int/news-room/fact-sheets/detail/rehabilitation. Accessed 2023.
84: Yuan F, Klavon E, Liu Z, Lopez RP, Zhao X. A systematic review of robotic rehabilitation for cognitive training. Front Robot AI 2021;8:605715. PMID 34046433

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Jonathan Tiu MD

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Outpatient rehabilitation of chronic neurologic conditions

Also Relevant

Cerebral palsy
Dysarthria
Dysphagia
Ischemic stroke
Non-progressive aphasia
- Parkinson disease
- Principles of rehabilitation of patients with neurologic disorders
- Peripheral neuropathies: supportive measures and rehabilitation
- Rehabilitation of spinal cord injury
- Secondary stroke prevention
- Spasticity

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General Neurology

Outpatient rehabilitation of chronic neurologic conditions

Outpatient rehabilitation of chronic neurologic conditions

Introduction

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Historical note and terminology

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Brain death/death by neurologic criteria

Hepatic encephalopathy

Bowel dysfunction in neurologic disorders

Coma due to primary brainstem and diencephalic lesions

Transient visual loss

Neuroimaging in acute stroke

Sports activities: neurologic complications

Neurotechnology: brain-computer and brain-machine interfaces

Outpatient rehabilitation of chronic neurologic conditions

Introduction

Overview

Key points

Historical note and terminology

Clinical aspects

Description

Indications

Contraindications

Outcomes

References

Contributors

Authors

Editor

Former Authors

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Brain death/death by neurologic criteria

Hepatic encephalopathy

Bowel dysfunction in neurologic disorders

Coma due to primary brainstem and diencephalic lesions

Transient visual loss

Neuroimaging in acute stroke

Sports activities: neurologic complications

Neurotechnology: brain-computer and brain-machine interfaces

This is an article preview.
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