Sign Up for a Free Account
  • Updated 11.14.2023
  • Released 02.27.2019
  • Expires For CME 11.14.2026

Outpatient rehabilitation of chronic neurologic conditions



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.

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

  • Nearly 3,000 illustrations, including video clips of neurologic disorders.

  • Every article is reviewed by our esteemed Editorial Board for accuracy and currency.

  • Full spectrum of neurology in 1,200 comprehensive articles.

  • Listen to MedLink on the go with Audio versions of each article.

Questions or Comment?

MedLink®, LLC

3525 Del Mar Heights Rd, Ste 304
San Diego, CA 92130-2122

Toll Free (U.S. + Canada): 800-452-2400

US Number: +1-619-640-4660



ISSN: 2831-9125