Table 1.

Strategies for Therapy That Clinicians Can Encourage after Hemiplegic Stroke.

Time and Setting	Focus	Example of Target
Week 1, acute hospitalization	Assessment	Assess ability to swallow and amount of assistance patient needs for activities of daily living
Weeks 2 to 6, inpatient rehabilitation	Assessment	Specify impairments, disabilities, and household barriers that are the goals of intervention
	Training in compensatory techniques	Train in one-handed dressing, bathing, using the toilet; if liquids (but not thicker substances) are aspirated during a modified barium swallow, use puréed foods and liquids the consistency of honey and instruct patient to rotate and flex the head to the weak side with each swallow and to double swallow (i.e., swallow food or liquid, then swallow again, to clear throat)
	Practicing components of impaired movement of affected limbs to achieve increasingly complex and task-specific actions	Have patient practice reaching for small items with the affected arm within the work space between the shoulder and lap, with the use of elbow support if needed, and opening the affected hand to match the diameter of an object, then grasping or pinching the object and releasing it
	Training that requires attention and is progressively more demanding, oriented toward tasks relevant to the patient, and rewarded with feedback	Monitor distance walked or time needed to walk 10 m; choose a self-care task and give feedback on the quality of movement and problem-solving during practice
Months 1 to 6, outpatient rehabilitation	Use of simple but relevant test–retest measures over the course of therapy to help monitor success or the need to try another approach	Serially record the distance walked in 5 min or time needed to loop shirt buttons; if patient has dysnomia, monitor the percentage of correctly named items; record the percentage of items found in the left half of a room as patient compensates for a left visual hemineglect
	Practice that is progressive in intensity and at levels of difficulty near maximal performance	Focus on the accuracy, precision, rate, and duration of performing each task; aim to increase walking speed to >0.75 m per sec for unlimited walking in the community
	Repetitive practice that varies tasks and their requirements	Have patient reach for cups and books on a shelf, clothes on hangers, items of different size and weight on a table, and practice for 20 min several times a day until performance is satisfactory
	Improvement in strength and endurance	Have patient exercise with elastic bands or hand weights or pedal on a recumbent bicycle or walk on a treadmill while mildly short of breath
	Task-oriented activities relevant to daily needs of patient and family	Have patient wash a car to use affected arm and challenge balance; attend employment setting with patient, to help develop strategies that make possible at least limited return to work
Beyond 6 months, individual goal setting	Improvement in skills needed in usual roles and out-of-home activities that satisfy unmet needs	Have patient increase walking speed or distance by 25%; patient with aphasia should read or listen to a story in a newspaper or newscast, then immediately incorporate words from the story into discussion, practicing these skills at varying levels of difficulty; improvement may require 20 hr of training