FND Week: The Fundamentals of Functional Neurologic Disorder

In Part 2 of our breakdown of the 2026 AHA/ASA Stroke Rehabilitation and Recovery Guidelines, we move from assessment into the interventions that shape day-to-day neurorehabilitation. This section gets into the questions clinicians deal with constantly: How much exercise should someone do after stroke? What should we actually be doing for gait, balance, spasticity, upper-extremity recovery, cognition, communication, vision, and community reintegration? The guideline makes a strong push toward individualized exercise and long-term physical activity, recommending 150 to 300 minutes of moderate-intensity activity per week, along with aerobic, strength, and balance training. It also emphasizes that exercise should continue beyond formal rehabilitation and become part of long-term stroke recovery. We also cover updated recommendations for gait and mobility, upper-extremity rehabilitation, apraxia, spasticity, balance and ataxia, plus the role of assistive devices and technology. The guideline specifically supports the use of AFOs or functional electrical stimulation for poststroke hemiplegia to improve balance and mobility, while reinforcing the importance of matching equipment to the person’s actual functional needs. Part 2 also expands beyond motor recovery. We break down recommendations for cognitive rehabilitation, aphasia, dysarthria, apraxia of speech, spatial neglect, visual impairment, dysphagia, and communication recovery, along with the growing role of technology and telerehabilitation. Finally, we look at what happens after formal therapy ends. The 2026 guideline places greater emphasis on caregiver support, community rehabilitation, continuity of care, return to work, return to driving, recreation, social participation, and long-term follow-up. Stroke rehabilitation is increasingly being framed not as a short episode of care, but as a process that continues into real life. If you work in stroke rehabilitation, this episode covers some of the most clinically relevant changes in the new guideline and what they may mean for the way we approach recovery moving forward.

In Part 1 of this two-part Neuro Simplified series, we break down the guideline from the beginning through Section 4.5, focusing on rehabilitation care, medical complications, and assessment after stroke. One of the biggest themes is that stroke rehabilitation does not have a defined endpoint. Recovery should be viewed as a longitudinal process, with reassessment and opportunities to re-engage in therapy throughout the lifespan. The guideline also emphasizes sufficient intensity and repetition of task-specific practice, while recommending that moderate to high intensity activity generally begin only after the first 24 hours following stroke. We discuss where rehabilitation should happen and why setting matters. For patients who qualify, inpatient rehabilitation facilities are recommended over skilled nursing facilities, while coordinated community-based rehabilitation and early supported discharge remain important options for appropriate patients. We also cover several recommendations that could directly change clinical practice, including: Why high-dose mobilization within the first 24 hours after stroke can be harmful, while graduated mobilization beginning around 24 to 48 hours is recommended. Updated approaches to hemiplegic shoulder pain, including botulinum toxin, neuromodulation, NMES, taping, injections, and other adjunct treatments. The guideline specifically recommends against overhead pulley exercises in patients with shoulder subluxation, weakness, or pain because of potential harm. New emphasis on fall prevention, including structured programs, balance training, dual-task training, tai chi, and annual fall-risk assessment. Stronger recommendations for poststroke depression and anxiety screening, including repeated screening throughout recovery and recognition that exercise, CBT, medications, and other interventions may play a role in treatment. Why clinicians should move beyond informal observation and routinely use standardized, validated outcome measures to assess disability, motor function, communication, cognition, perception, vision, hearing, and sensory impairment. This first episode focuses on what clinicians should be doing before we even get into the major treatment recommendations. Part 2 will continue into the sensorimotor, gait, upper-extremity, cognition, communication, community reintegration, return-to-work, and return-to-driving sections. Source: Richards LG, Ifejika NL, Stein J, et al. 2026 Guideline for Adult Stroke Rehabilitation and Recovery: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2026;57:e514-e658. doi:10.1161/STR.0000000000000536. Powered by Google Notebook LM

Robotic gait training is one of the most eye-catching technologies in neurorehabilitation, but does it actually outperform high intensity walking after stroke? In this episode of Neuro Simplified, we compare robotic rehabilitation and high intensity walking training for improving gait and mobility after stroke. The study challenges a common assumption in rehab: more advanced technology does not always mean better outcomes. High intensity walking produced stronger improvements in key walking measures than robotic-assisted rehabilitation, highlighting the importance of training intensity, repetition, cardiovascular demand, and task-specific practice. We break down why higher-intensity walking may drive better recovery, where robotic gait training may still be useful, and how clinicians can decide when technology adds value versus when it may simply reduce the training stimulus. This episode also looks at the bigger question for stroke rehab: Is robotic rehabilitation the future, or is high intensity walking still the better tool for recovery?

Bone loss after spinal cord injury can happen quickly, progress for years, and often goes unnoticed until a fracture occurs. In this episode of Neuro Simplified, we break down sublesional osteoporosis after spinal cord injury, why bone mineral density decreases below the level of injury, which areas are most vulnerable, and what clinicians should actually be screening for. The clinical practice guideline defines sublesional osteoporosis as bone loss occurring below the neurological level of injury and emphasizes that bone health should be addressed across the lifespan after SCI. CPG_Spinal-Cord-Medicine_2022_F… Fracture risk is not trivial. The guideline reports that approximately 20% to 46% of individuals with SCI may experience a fracture during their lifetime, with fragility fractures occurring most commonly around the distal femur and proximal tibia. Transfers and falls are among the most frequently reported mechanisms. CPG_Spinal-Cord-Medicine_2022_F… We also discuss why a standard osteoporosis workup may miss the areas that matter most after SCI. Current recommendations call for DXA assessment of the total hip, distal femur, and proximal tibia once medically stable, with these same regions used to assess fracture risk and monitor treatment. CPG_Spinal-Cord-Medicine_2022_F… Then we get into the rehabilitation question: Can standing, walking, FES, or NMES actually protect bone? Passive standing may help slow bone loss when performed consistently, but evidence for reversing established osteoporosis is limited. FES and NMES appear more promising when they create strong muscle contractions against resistance, but the dose matters. Recommendations generally involve at least 30 minutes, 3 to 5 days per week, for a year or longer. CPG_Spinal-Cord-Medicine_2022_F… This episode covers what physical therapists and other rehabilitation clinicians should know about bone loss after SCI, fracture risk, DXA screening, electrical stimulation, weight bearing, and why maintaining bone health requires a long-term approach. Source: Bone Health and Osteoporosis Management in Individuals with Spinal Cord Injury: Clinical Practice Guideline for Health Care Providers. Consortium for Spinal Cord Medicine, Paralyzed Veterans of America. 2022. Powered by Google Notebook LM

In this episode of Neuro Simplified, we break down a 2024 systematic review examining vagus nerve stimulation, or VNS, paired with rehabilitation for motor recovery after neurological injury. The review included animal studies in stroke, traumatic brain injury, and spinal cord injury, along with human studies in stroke. The key idea is simple. VNS may help drive neuroplasticity by activating pathways involved in the release of neuromodulators like norepinephrine, acetylcholine, serotonin, and brain-derived neurotrophic factors. When stimulation is paired with successful movement practice, it may help reinforce the neural networks involved in recovery. In human stroke studies, both invasive and non-invasive VNS showed promising motor improvements. In the non-invasive studies, upper-extremity Fugl-Meyer scores improved more in the VNS groups than controls in several trials, with relative improvements ranging from 8% to 27%. We discuss why the timing of stimulation may matter just as much as the stimulation itself, how VNS could enhance task-specific training, and whether this technology represents a meaningful shift in upper-extremity stroke rehabilitation. Source: Korupolu R, Miller A, Park A, Yozbatiran N. Neurorehabilitation with vagus nerve stimulation: a systematic review. Front Neurol. 2024;15:1390217. doi:10.3389/fneur.2024.1390217. Powered by Google Notebook LM