Stroke: posthospital management and recurrence prevention.

There is no defined duration of therapy for stroke patients, who may continue to experience recovery for several months after the event. Physical, occupational, and speech therapy should be offered as long as benefit is experienced. Patients may benefit from self-directed therapy. Constraint-induced movement therapy, a rigorous program for upper extremity weakness, has been proven effective for improving arm function. Other areas of investigation include repetitive transcranial magnetic stimulation, cellular management, robotic therapy, and pharmacologic strategies to enhance recovery. OnabotulinumtoxinA (formerly botulinum toxin A) is effective for treating spasticity in the arm after stroke. Depression, experienced by at least one-third of patients after stroke, should be managed, and selective serotonin reuptake inhibitors may offer an additional advantage of improved motor recovery. Proven interventions for secondary prevention after stroke include carotid revascularization, anticoagulation for patients with atrial fibrillation, aggressive medical management for those with significant intracranial atherosclerosis, statin treatment for patients with atherosclerotic stroke and low-density lipoprotein cholesterol levels of 100 to 190 mg/dL, antiplatelet therapy for nonatrial fibrillation stroke, and blood pressure reduction. Vitamin and dietary supplements are of unproven benefit for stroke patients. Exercise, smoking cessation, and a healthful diet should be encouraged. Return to driving and sexual activity also should be addressed during outpatient follow-up.

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