Early Recovery & Rehabilitation Principles
Stroke is the leading cause of long-term disability worldwide. In the United States, more than two-thirds of stroke survivors receive post-acute rehabilitation services after hospital discharge. While neurologists focus heavily on hyperacute management and secondary prevention, the weeks to months of recovery that follow determine whether patients regain independence. Understanding rehabilitation principles, disposition pathways, dysphagia management, and the evidence for (and against) pharmacologic recovery aids is essential for every practicing neurologist.
🔹 Bottom Line: Early Recovery & Rehabilitation
- Mobilization timing: High-dose very early mobilization (<24h) is harmful (Class 3, AVERT). Begin mobilization after 24 hours when medically stable.
- Interdisciplinary rehab: Formal in-hospital assessment and provision of rehabilitation improves functional recovery (Class 1, LOE A — 2026 AIS Guideline).
- SSRIs for motor recovery: Definitively negative. EFFECTS, FOCUS, and AFFINITY (combined N > 5,900) show no benefit for functional outcomes. SSRIs increase fractures, falls, and seizures. Class 3: No Benefit for motor recovery.
- Disposition matters: Acute inpatient rehabilitation (IRF) produces better outcomes than SNF for appropriate candidates — proper selection using FIM scores and the CMS 3-hour/60% rules is critical.
- Dysphagia screening: Must occur before any oral intake (Class 1). Aspiration pneumonia is a leading cause of post-stroke death and is largely preventable.
- Neuroplasticity: Most rapid gains occur in the first 3 months, but meaningful recovery continues up to 12+ months. Plateau is not a ceiling — ongoing task-specific practice drives gains.
1. Timing of Mobilization
The question of when to get stroke patients out of bed was answered definitively by the AVERT trial (A Very Early Rehabilitation Trial, 2015). This landmark study randomized 2,104 patients (ischemic and hemorrhagic stroke) to very early mobilization (initiated within 24 hours, median 18.5 hours, with ≥3 additional out-of-bed sessions focused on sitting, standing, and walking) versus usual care (median 22.4 hours, standard activity).
The results were counterintuitive to many clinicians: patients in the very early mobilization group had worse outcomes. Favorable outcome (mRS 0–2) at 3 months was 46% in the early mobilization group versus 50% in usual care (adjusted OR 0.73, 95% CI 0.59–0.90, p=0.004). Mortality trended higher with early mobilization (8% vs 7%). A subsequent meta-analysis including AVERT and several smaller RCTs confirmed no benefit from very early mobilization.
An important nuance from AVERT is the dose-response relationship: it was the frequency and intensity of early activity — not just the timing — that appeared harmful. Post-hoc analyses suggested that shorter, less frequent early sessions may not carry the same risk, though this has not been validated prospectively.
🔹 Clinical Relevance: Mobilization After Acute Stroke
- 2026 AIS Guideline: High-dose, very early mobilization within 24 hours is Class 3: Harm (LOE B-R).
- Post-IVT: Wait at least 12–24 hours post-thrombolysis before initiating mobilization. Assess neurological stability and ensure no hemorrhagic conversion.
- Post-EVT: Access site considerations (groin rest 4–6 hours for femoral approach) in addition to neurological stability before mobilization.
- Practical approach: Mobilize after 24 hours when medically and neurologically stable. Start with bed-edge sitting, progress to standing and walking as tolerated. Physical therapy should assess before first mobilization.
- Knowledge gap: The optimal dose, frequency, and timing of in-hospital rehabilitation initiation remain unclear. Research using wearable technology and machine learning may help individualize rehabilitation intensity.
2. Neuroplasticity Principles for Neurologists
Understanding the biological basis of post-stroke recovery helps neurologists set realistic expectations, counsel patients, and understand why rehabilitation works. The brain's capacity for reorganization after injury — neuroplasticity — is the foundation of all rehabilitation interventions.
Key Neuroplasticity Principles
Use-dependent plasticity: Repeated, task-specific practice strengthens synaptic connections in peri-infarct and contralesional circuits. This is why rehabilitation focuses on repetitive, goal-directed activity rather than passive range of motion alone. The corollary — "learned non-use" — occurs when patients stop attempting to use an affected limb, and the cortical representation shrinks further.
Critical recovery windows: The most rapid neurological gains occur in the first 3 months after stroke, driven by resolution of perilesional edema and diaschisis (remote functional depression), combined with early synaptogenesis. However, meaningful recovery continues up to 6–12 months and beyond with sustained rehabilitation. The concept of a "plateau" — once used to justify discontinuing rehabilitation services — is increasingly recognized as a reflection of reduced therapy intensity rather than a true biological ceiling.
Proportional recovery rule: Approximately 70% of patients recover a fixed proportion (~70%) of their initial motor deficit within the first 3 months (the "fitters"). The remaining ~30% ("non-fitters") recover far less. The key predictor distinguishing these groups is integrity of the corticospinal tract, assessed clinically by the presence or absence of motor-evoked potentials (MEPs) on transcranial magnetic stimulation (TMS). Patients with intact MEPs at 1 week tend to follow proportional recovery; absent MEPs predict poor recovery of hand function regardless of therapy intensity.
Brunnstrom Stages of Motor Recovery
Signe Brunnstrom described seven stages of motor recovery following stroke that remain the most widely used clinical framework in rehabilitation. Understanding these stages helps neurologists interpret rehabilitation progress notes and communicate with PM&R colleagues.
| Stage | Description | Clinical Correlate |
|---|---|---|
| I | Flaccidity — no voluntary movement | Immediate post-stroke. Limb is hypotonic, areflexic. High subluxation risk. |
| II | Spasticity begins, basic synergies appear | Limb begins to develop tone. Voluntary movement only within mass flexion or extension synergies (e.g., attempting to flex elbow also causes shoulder abduction and wrist flexion simultaneously). |
| III | Spasticity peaks, synergies strengthen | Strong spasticity. Voluntary control remains locked in synergy patterns. Patient can initiate movement but cannot isolate individual joints. |
| IV | Spasticity decreases, some isolated movements | First out-of-synergy movements appear (e.g., hand to lower back, wrist extension with elbow extended). This is a pivotal stage — the transition from synergy-dependent to selective motor control. |
| V | Synergies lose dominance, complex movements possible | Increasing independence from synergies. Most movements can be performed selectively. Spasticity minimal. Fine motor still impaired. |
| VI | Spasticity disappears, near-normal coordination | Individual joint movements freely performed. Speed and coordination approaching normal. May have mild clumsiness with rapid alternating movements. |
| VII | Normal motor function restored | Full recovery of speed, coordination, and strength. Achieved by a minority of patients. |
What Predicts Motor Recovery?
| Factor | Good Prognosis | Poor Prognosis |
|---|---|---|
| Corticospinal tract integrity | Intact MEPs on TMS; preserved motor fibres on DTI | Absent MEPs; Wallerian degeneration on DTI |
| Initial severity (UE) | Some voluntary finger extension at day 2–3 | No voluntary finger movement at day 7 |
| Stroke location | Cortical, sparing corona radiata/PLIC | Posterior limb internal capsule (PLIC), pontine base |
| Age | Younger (more neuroplastic reserve) | Older (reduced plasticity, comorbidities) |
| Cognitive status | Intact cognition, able to participate in therapy | Severe neglect, aphasia limiting therapy engagement |
| Pre-stroke function | Independent (mRS 0–1) | Prior disability (mRS ≥3) |
3. The Rehabilitation Team
Organized inpatient stroke unit care — most of which includes interdisciplinary rehabilitation assessments — produces better outcomes than care on general medical wards (Cochrane: Stroke Unit Trialists' Collaboration). For neurologists who consult or co-manage stroke patients, understanding who does what in the rehab team enables more effective communication and care planning.
| Team Member | Role | What They Assess |
|---|---|---|
| Physiatrist (PM&R) | Rehabilitation physician; leads the rehab team, manages medical issues during rehab, prescribes therapies, orthotics, and adaptive equipment | Functional capacity, rehab goals, discharge disposition, pain management, spasticity |
| Physical Therapist (PT) | Mobility, gait, balance, transfers, wheelchair assessment, lower extremity strengthening | Gait pattern, balance (Berg Balance Scale), transfer ability, stair climbing, endurance, fall risk |
| Occupational Therapist (OT) | Activities of daily living (ADLs), upper extremity function, cognitive retraining, home safety, adaptive equipment | Self-care (dressing, bathing, feeding, grooming), fine motor function, visual-perceptual skills, home modifications |
| Speech-Language Pathologist (SLP) | Swallowing assessment and therapy, language/communication rehabilitation, cognitive-linguistic therapy | Dysphagia severity (bedside + instrumental), aphasia type and severity (WAB), dysarthria, cognitive communication |
| Neuropsychologist | Comprehensive cognitive assessment, emotional/behavioral management, adjustment counseling | Detailed cognitive domains (executive function, memory, attention, visuospatial), depression screening, capacity assessments |
| Rehabilitation Nurse | Skilled nursing, bowel/bladder program, medication management, skin integrity, patient/family education | Neurological status monitoring, functional carryover of therapy gains, safety |
| Social Worker / Case Manager | Discharge planning, insurance navigation, community resources, caregiver support, psychosocial assessment | Social support system, financial resources, home environment, long-term care needs |
4. Functional Assessment Tools
Functional Independence Measure (FIM)
The FIM is the most widely used standardized functional assessment tool in rehabilitation. Every neurologist reviewing rehab documentation encounters FIM scores, yet most neurology training programs do not teach its interpretation. Understanding the FIM enables meaningful communication with PM&R teams and informed disposition decisions.
The FIM contains 18 items across two domains: motor (13 items) and cognitive (5 items). Each item is scored on a 7-point ordinal scale from 1 (total assistance — patient performs <25% of task) to 7 (complete independence). The maximum total score is 126 (motor max 91, cognitive max 35).
| FIM Score | Level of Assistance | % Patient Performs | Practical Meaning |
|---|---|---|---|
| 7 | Complete Independence | 100% | No helper needed, uses no device, performs safely in reasonable time |
| 6 | Modified Independence | 100% | Uses adaptive device, takes extra time, or has safety concerns — but no helper |
| 5 | Supervision / Setup | 100% | Requires standby cueing, coaxing, or setup — helper present but doesn't touch |
| 4 | Minimal Contact Assist | ≥75% | Patient does most of the effort; helper provides light touch or guidance |
| 3 | Moderate Assist | 50–74% | Patient does more than half; helper provides moderate physical assistance |
| 2 | Maximal Assist | 25–49% | Patient does less than half; helper provides most of the effort |
| 1 | Total Assist | <25% | Patient contributes little to nothing; requires full physical assistance |
The motor FIM items are: eating, grooming, bathing, dressing upper body, dressing lower body, toileting, bladder management, bowel management, bed/chair/wheelchair transfer, toilet transfer, tub/shower transfer, walk/wheelchair locomotion, and stairs. The cognitive FIM items are: comprehension, expression, social interaction, problem solving, and memory.
Other Key Assessment Tools
| Tool | What It Measures | When Used | Key Details |
|---|---|---|---|
| Barthel Index | Basic ADL independence | Clinical trials, longitudinal tracking | 10 items, score 0–100. Simpler than FIM but less sensitive to change. ≥60 = "moderate dependence" |
| mRS | Global disability | Clinical trials (primary outcome), clinical documentation | Single scale 0–6. 0 = no symptoms, 2 = slight disability (independent), 3 = moderate (needs help but walks), 6 = dead |
| NIHSS | Neurological impairment (not function) | Acute stroke assessment, clinical trials | 15 items, score 0–42. Measures deficit, NOT disability. Patient with NIHSS 2 (mild) may still be highly disabled if deficit affects critical function (e.g., dominant hand) |
| Fugl-Meyer (FMA-UE) | Upper extremity motor function | Research, emerging clinical use | 66-point UE scale. <19 = severe, 19–47 = moderate, 48–66 = mild. Used in VNS-REHAB, CARS, and most motor recovery trials |
| Action Research Arm Test (ARAT) | Upper limb functional capacity | Research (CARS, robotics trials) | 57-point scale. Tests grasp, grip, pinch, and gross movement. More task-oriented than Fugl-Meyer |
🔹 Clinical Relevance: NIHSS vs FIM — Why Both Matter
- NIHSS measures neurological impairment — the deficit itself (weakness, language, neglect).
- FIM measures functional disability — what the patient can actually do despite the deficit.
- A patient with NIHSS 4 (moderate) who has isolated hand weakness may have FIM 110 (largely independent) because they can compensate with the other hand.
- A patient with NIHSS 4 who has moderate neglect may have FIM 60 (needs significant assistance) because neglect impairs safety, navigation, and self-care.
- Rehabilitation targets disability (FIM), not impairment (NIHSS). A patient may improve functionally (FIM gains) without neurological change (NIHSS stable) — through compensation, adaptive equipment, and environmental modification.
5. Rehabilitation Disposition Decision-Making
Selecting the appropriate post-acute setting is one of the most impactful decisions a neurologist makes for a stroke patient — yet it receives minimal training attention. Getting it right improves outcomes; getting it wrong wastes critical recovery time.
| Setting | Requirements / Criteria | Therapy Intensity | Typical Patient |
|---|---|---|---|
| Acute Inpatient Rehabilitation (IRF) | CMS 60% rule: ≥60% of patients must have qualifying diagnosis (stroke qualifies). CMS 3-hour rule: patient must tolerate ≥3 hours of therapy per day, 5–7 days/week. Requires ≥2 therapy disciplines. Physician supervision (face-to-face 3x/week). Medical stability. Realistic functional goals achievable in expected LOS (typically 14–21 days for stroke). | ≥3 hours/day, 5–7 days/week | Moderate-severe deficits, medically stable, cognitively able to participate, motivated, has clear functional goals, caregiver support for discharge |
| Skilled Nursing Facility (SNF) | Requires skilled nursing or therapy services. No specific therapy hour requirement (typically 1–2 hours/day). Medicare covers first 20 days at 100%, then copay days 21–100. | 1–2 hours/day, 5 days/week | Cannot tolerate 3 hours/day of therapy, multiple comorbidities, limited endurance, significant cognitive impairment limiting participation, awaiting long-term placement |
| Long-Term Acute Care Hospital (LTACH) | Average LOS >25 days. For medically complex patients who still need hospital-level care but are no longer acutely ill. Ventilator weaning, complex wound care, IV antibiotics, TPN. | Variable, often limited by medical complexity | Prolonged ICU course, ventilator-dependent, complex medical needs (tracheostomy, PEG management), not yet stable enough for IRF or SNF |
| Home Health | Patient is homebound (leaving home requires considerable effort). Requires skilled nursing or therapy. Has safe home environment and caregiver support. | 2–3 sessions/week per discipline | Mild-moderate deficits, ambulatory with device, safe home environment, reliable caregiver, can manage basic ADLs with minimal assistance |
| Outpatient Therapy | Patient can travel to therapy center. Ambulatory (with or without device). Can tolerate 1–3 sessions per week. | 2–3 sessions/week per discipline | Mild deficits, independent in most ADLs, able to travel, ongoing specific rehabilitation goals (gait training, UE strengthening, speech therapy) |
🔴 Common Disposition Pitfalls
- Sending an IRF-appropriate patient to SNF: Patients who can tolerate 3 hours/day of therapy recover faster and more completely in an IRF. SNF provides less intensive therapy and fewer physician oversight hours. Studies show IRF patients have higher rates of community discharge and functional independence.
- Assuming severe aphasia precludes IRF: Aphasia alone does not prevent meaningful participation in PT and OT. Many aphasic patients tolerate 3 hours/day of therapy and benefit substantially from intensive SLP services available at IRFs.
- Cognitive impairment: Moderate cognitive impairment does not automatically disqualify a patient from IRF. If the patient can follow 1-step commands and participate in structured therapy with cueing, they may be appropriate. Severe neglect, agitation, or inability to follow commands typically precludes IRF.
- Waiting too long: Rehabilitation initiated within 3 days of hospital admission is associated with better ADL outcomes. Early rehab consultation and disposition planning reduce delays.
6. Dysphagia Assessment & Management
Dysphagia affects 37–78% of acute stroke patients depending on detection method (bedside screening vs instrumental assessment). Aspiration pneumonia is a leading cause of post-stroke mortality and is largely preventable with systematic screening and management. The 2026 AIS Guideline mandates dysphagia screening before any oral intake (Class 1, LOE B-NR).
Bedside Screening
Nurse-administered dysphagia screening should occur within the first 24 hours before the patient receives any food, liquid, or oral medication. Two validated tools are most commonly used:
| Screening Tool | Components | Sensitivity | Key Features |
|---|---|---|---|
| Yale Swallow Protocol | Orientation screen (cognition) + 3 oz water swallow test (drink entire cup without interruption) | ~97% | Pass/fail. If patient fails cognitive screen, automatically fails swallow screen. Simple, fast (~5 min). Validated in stroke population. |
| TOR-BSST (Toronto Bedside Swallowing Screening Test) | Tongue movement + water swallow (sequential 50 mL teaspoons then cup) with voice quality assessment | ~92% | Any abnormal response triggers SLP referral. Takes ~10 min. Requires brief training. High NPV. |
Key point: If the patient fails bedside screening, they remain NPO (nothing by mouth) and an SLP referral is placed for formal assessment. If the patient passes, cautious oral intake may begin, but instrumental assessment is still warranted if clinical suspicion for silent aspiration exists (common in brainstem and bilateral strokes).
Instrumental Swallowing Assessment
| Feature | FEES (Fiberoptic Endoscopic Evaluation) | VFSS (Videofluoroscopic Swallow Study) |
|---|---|---|
| Method | Flexible laryngoscope passed transnasally; patient swallows dyed food/liquid while SLP observes pharyngeal phase directly | Patient swallows barium-coated food/liquid of varying consistencies under fluoroscopy; images recorded in real-time (also called Modified Barium Swallow) |
| What it shows | Pharyngeal residue, laryngeal penetration/aspiration, secretion management, velopharyngeal closure, vocal cord function | Full swallowing sequence: oral preparation → oral transit → pharyngeal → upper esophageal sphincter. Visualizes aspiration timing (before, during, or after swallow) |
| Advantages | Portable (bedside in ICU/stroke unit), no radiation, repeatable, directly visualizes anatomy, can assess secretion management in NPO patients | Gold standard for comprehensive swallow physiology, visualizes oral phase (FEES cannot), identifies esophageal pathology, establishes temporal relationship of aspiration to swallow |
| Limitations | Cannot visualize oral phase or during-swallow moment ("white-out" during swallow), requires trained SLP, mild patient discomfort | Requires transport to radiology, radiation exposure, limited by patient positioning, does not directly visualize anatomy |
| When to order | ICU patients who cannot transport, suspected silent aspiration, need to assess secretion management, serial reassessments | Need complete swallow physiology including oral phase, suspected esophageal dysphagia, treatment planning for oral/pharyngeal exercises |
The IDDSI Framework
The International Dysphagia Diet Standardisation Initiative (IDDSI) replaced the outdated and inconsistent terminology previously used for modified diets (e.g., "honey-thick," "nectar-thick," "mechanical soft"). IDDSI provides a globally standardized framework with 8 levels (0–7) that cover both drinks and foods:
| Level | Name | Applies To | Description / Testing Method |
|---|---|---|---|
| 0 | Thin | Drinks | Water, tea, coffee — flows like water |
| 1 | Slightly Thick | Drinks | Thicker than water, flows through straw (formerly "nectar-like") |
| 2 | Mildly Thick | Drinks | Effort needed with straw, pours slowly (formerly "nectar-thick") |
| 3 | Liquidised / Moderately Thick | Both | Smooth texture with no lumps; can be drunk from cup or eaten with spoon (formerly "honey-thick") |
| 4 | Pureed / Extremely Thick | Both | Cannot be drunk from cup; must be eaten with spoon; falls off spoon in single spoonful (formerly "pudding-thick") |
| 5 | Minced & Moist | Foods | Small lumps ≤4 mm; can be mashed with fork; no chewing required |
| 6 | Soft & Bite-Sized | Foods | Pieces ≤1.5 cm; can be mashed with fork; some chewing required |
| 7 | Regular / Easy to Chew | Foods | Normal or soft/tender foods; full chewing ability |
Aspiration Pneumonia Prevention & PEG Timing
Aspiration pneumonia prevention requires a multi-modal approach: oral care (chlorhexidine oral rinse reduces bacterial load), upright positioning during and for 30 minutes after meals, appropriate diet texture modification per IDDSI, chin-tuck maneuver if recommended by SLP, and close monitoring for signs of aspiration (cough with meals, wet/gurgly voice, unexplained fever).
PEG timing: If dysphagia is expected to persist beyond 2–4 weeks, percutaneous endoscopic gastrostomy (PEG) should be considered. Prolonged nasogastric (NG) tube feeding beyond 2–3 weeks is associated with increased sinusitis, erosions, patient discomfort, and tube dislodgement. Early PEG placement (within 14 days) facilitates discharge to rehabilitation and ensures adequate nutrition during the critical recovery period. Nutritional assessment by a dietitian should occur within 48 hours for all stroke patients with dysphagia — malnutrition is common and independently worsens outcomes.
7. SSRIs for Motor Recovery — The Definitive Answer
For nearly a decade, the possibility that fluoxetine could enhance motor recovery after stroke generated considerable excitement. The story of this hypothesis — and its definitive refutation — illustrates why large, well-powered trials are essential before changing practice.
The FLAME trial (2011, N=118) was a single-center French RCT that randomized patients with moderate-to-severe motor deficits to fluoxetine 20 mg daily or placebo for 3 months, alongside standard rehabilitation. The results were striking: fluoxetine patients showed significantly greater improvement in Fugl-Meyer motor scores (+34 vs +24 points, p=0.003) and more achieved mRS 0–2 at 90 days (26% vs 9%, p=0.015). This small trial fueled widespread off-label use of fluoxetine for stroke recovery.
Three large, pragmatic, multicenter RCTs then definitively tested this hypothesis:
| Trial | Year | N | Population | Primary Outcome (mRS) | Key Safety Findings |
|---|---|---|---|---|---|
| FOCUS | 2019 | 3,127 | Ischemic or hemorrhagic stroke, 2–15 days post-onset | No difference (adjusted OR 0.951, 95% CI 0.839–1.079, p=0.44) | Fewer new depression diagnoses; more bone fractures (2.9% vs 1.5%) |
| AFFINITY | 2020 | 1,280 | Ischemic or hemorrhagic stroke, 2–15 days post-onset | No difference (adjusted OR 0.936, 95% CI 0.762–1.150, p=0.53) | More falls (3% vs 1%, p=0.018); more seizures (2% vs <1%, p=0.038) |
| EFFECTS | 2020 | 1,494 | Ischemic or hemorrhagic stroke, 2–15 days post-onset | No difference (adjusted OR 0.94, 95% CI 0.78–1.13, p=0.52) | Reduced new depression (13.2% vs 17.2%); more fractures (2.9% vs 1.5%); more hyponatremia (2.2% vs 0.7%) |
A subsequent Cochrane systematic review including more than 13,000 participants confirmed no significant differences between SSRIs and placebo for either disability (standardized mean difference −0.0, 95% CI −0.05 to 0.05) or independence (risk ratio 0.98, 95% CI 0.93–1.03).
🔹 Clinical Relevance: SSRIs After Stroke
- 2026 AIS Guideline: SSRIs are Class 3: No Benefit (LOE A) for improving motor recovery or functional status after stroke.
- For depression treatment: SSRIs remain appropriate and effective for treating diagnosed post-stroke depression. Network meta-analyses support SSRIs (particularly paroxetine) as effective antidepressants in PSD. But this is treatment of depression — not a neurorecovery strategy.
- Harm signals: All three major trials showed increased bone fractures. AFFINITY additionally showed increased falls and seizures. Monitor patients carefully if prescribing SSRIs for any indication post-stroke.
- Take-home: Do not routinely prescribe fluoxetine (or any SSRI) to stroke patients without depression in hopes of enhancing recovery. The FLAME trial was a false positive — underpowered, single-center, and not replicated.
8. Trial Comparison Table
| Trial | Year | N | Intervention | Primary Outcome | Result |
|---|---|---|---|---|---|
| AVERT | 2015 | 2,104 | Very early mobilization (<24h) vs usual care | mRS 0–2 at 3 months | Harmful: 46% vs 50% (aOR 0.73, p=0.004). Class 3 Harm. |
| FLAME | 2011 | 118 | Fluoxetine 20 mg vs placebo × 3 months | FMMS improvement at 90 days | Positive: +34 vs +24 (p=0.003). Single-center, not replicated. |
| FOCUS | 2019 | 3,127 | Fluoxetine 20 mg vs placebo × 6 months | mRS distribution at 6 months | Negative: aOR 0.951, p=0.44. Increased fractures. |
| AFFINITY | 2020 | 1,280 | Fluoxetine 20 mg vs placebo × 6 months | mRS distribution at 6 months | Negative: aOR 0.936, p=0.53. Increased falls and seizures. |
| EFFECTS | 2020 | 1,494 | Fluoxetine 20 mg vs placebo × 6 months | mRS distribution at 6 months | Negative: aOR 0.94, p=0.52. Reduced depression, increased fractures. |
| Stroke Unit Trialists (Cochrane) | 2020 | Meta-analysis | Organized stroke unit care vs general ward | Death or dependency | Positive: OR 0.75 (0.66–0.85). Strong evidence for interdisciplinary care. |
References
- AVERT Trial Collaboration group. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet. 2015;386:46–55.
- Prabhakaran S, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke. Stroke. 2026;57:e00–e00.
- FOCUS Trial Collaboration. Effects of fluoxetine on functional outcomes after acute stroke (FOCUS). Lancet. 2019;393:265–274.
- AFFINITY Trial Collaboration. Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY). Lancet Neurol. 2020;19:651–660.
- EFFECTS Trial Collaboration. Safety and efficacy of fluoxetine on functional recovery after acute stroke (EFFECTS). Lancet Neurol. 2020;19:661–669.
- Legg LA, et al. Selective serotonin reuptake inhibitors (SSRIs) for stroke recovery. Cochrane Database Syst Rev. 2021;11:CD009286.
- Chollet F, et al. Fluoxetine for motor recovery after acute ischaemic stroke (FLAME). Lancet Neurol. 2011;10:123–130.
- Langhorne P, et al. Organised inpatient (stroke unit) care for stroke: network meta-analysis. Cochrane Database Syst Rev. 2020;4:CD000197.
- Winstein CJ, et al. Guidelines for adult stroke rehabilitation and recovery: AHA/ASA guideline. Stroke. 2016;47:e98–e169.
- Stinear CM, et al. Proportional motor recovery after stroke: implications for trial design. Stroke. 2017;48:795–798.
- Li Z, et al. Effects of early mobilization after acute stroke: a meta-analysis. J Stroke Cerebrovasc Dis. 2018;27:1326–1337.
- Cichon N, et al. IDDSI Framework: international standards for texture-modified foods and thickened liquids. Dysphagia. 2017;32:293–296.