Rehabilitation after stroke: exercises, medications and recovery techniques

Medically reviewed: 25, December 2023

Rehabilitation after stroke: A comprehensive guide for medical professionals and patients

Rehabilitation after stroke is an integral part of management. A recent guideline authored by the Agency for Health Care Policy and Research outlines the strategies to maximize recovery.

Key Takeaways

• Rehabilitation after stroke helps individuals recover from physical, cognitive, and emotional challenges resulting from stroke.
• Stroke occurs when the blood supply to the brain is interrupted, leading to brain damage.
• Rehabilitation after stroke is designed to help individuals regain their function and independence.

Rehabilitation and life after stroke

Stroke is a serious medical condition that occurs when the blood supply to a part of the brain is interrupted, causing brain cells to die and brain functions to be impaired. This condition is a leading cause of death and disability worldwide, affecting millions of people every year. Stroke can have devastating consequences for the survivors and their families, such as physical, cognitive, emotional, and social impairments, reduced quality of life, and increased dependency and burden.

Rehabilitation after stroke is the process of restoring the abilities and functions that have been lost or impaired due to stroke, as well as preventing or minimizing the complications and secondary problems that may arise after stroke. It involves the collaboration of various health professionals, such as physicians, nurses, physiotherapists, occupational therapists, speech and language therapists, psychologists, social workers, and others, as well as the active participation and engagement of the patients and their families. Coming back to life after stroke is a dynamic and individualized process that depends on the type, severity, and location of the stroke, the age, health, and preferences of the patient, the availability and accessibility of the resources and services, and the goals and expectations of the rehabilitation team and the patient.

A key to successful rehabilitation is a coordinated team approach that involves active participation of several rehabilitation specialists. Rehabilitation should begin as soon as the patient is medically stable.

Education of the patient and family members about stroke and its consequences is an important step in rehabilitation. For example, the family should be informed about the nature of the neurologic impairments. In particular, they should be appraised of any prominent cognitive or emotional sequelae, such as:

• Language impairments
• Sleep disturbances
• Depression.

Patients with major strokes in the nondominant hemisphere may not exhibit much emotionality and may not be aware of other persons’ emotional status.

Physical therapists concentrate on:

• Mobilization
• Walking
• Major motor and sensory impairments of the limbs.

Speech pathologists address:

• Language or articulation impairments
• Disorders of swallowing.

Occupational therapists focus on:

• Fine motor movements of the hands
• Arm function
• Utilization of tools.

Patients should be assessed by these professionals and a treatment plan be tailored to each patients’ individual impairments and abilities. Rehabilitation plans should respect the wishes of the patients and families and the patients’ neurologic and general medical status. It is also important to enlist the assistance of a:

• Social service specialist
• Discharge planner
• Dietitian
• Nurse.

While the preliminary steps in rehabilitation begin in the acute care setting, a strategy should be developed for continued outpatient and inpatient rehabilitation.

In the United States, patients are eligible for intensive inpatient rehabilitation in an acute-care or stand-alone rehabilitation facility if they need at least two rehabilitation modalities (speech, occupational, physical) and if they can tolerate at least 3 hours of treatment daily.

Skilled nursing facilities can provide inpatient rehabilitation for those who cannot tolerate the more intensive inpatient care. Patients with minimal deficits can be treated as outpatients.

Patients are assessed at regular intervals during their recovery from stroke. The types of and settings for rehabilitation are adjusted in response to the patients’ conditions. The goal will be for the individuals to be as independent as possible. As the patients recover, the following issues should be addressed:

• Sexuality
• Returning to work
• Driving an automobile.

The patients’ living quarters may need to be modified to permit a return to home. In order to accommodate the patients’ impairments, alterations should be made to such facilities as:

• Toilet
• Bath
• Rugs
• Stairs
• Kitchen.

Rehabilitation after stroke is a crucial and beneficial process that can improve the outcomes and prognosis of the stroke survivors, such as enhancing their recovery and function, reducing their disability and mortality, increasing their independence and participation, and improving their well-being and satisfaction. Rehabilitation after stroke is a lifelong and holistic process that requires continuous assessment, intervention, and evaluation, as well as adaptation and adjustment to the changing needs and circumstances of the patient and the environment.

Understanding stroke: most common types of a stroke

Stroke is a serious medical condition that occurs when the blood supply to a part of the brain is interrupted, causing brain cells to die and brain functions to be impaired. Stroke can be classified into two main types:

Ischemic stroke

This is the most common type of stroke, which accounts for about 80% of all strokes. Ischemic stroke occurs when a blood vessel that supplies blood to the brain is blocked by a clot, plaque, or other substance, reducing or stopping the blood flow to the affected area. Ischemic stroke can be further divided into two subtypes:

Thrombotic stroke

Occurs when a clot forms inside a blood vessel that is already narrowed or damaged by atherosclerosis, which is the buildup of fatty deposits on the inner walls of the arteries. Thrombotic stroke is more common in older people and people with risk factors such as high blood pressure, high cholesterol, diabetes, smoking, or heart disease.

Embolic stroke

Happens when a clot or other material travels from another part of the body, such as the heart, and lodges in a blood vessel that supplies blood to the brain. Embolic stroke is more common in people with conditions that affect the heart, such as atrial fibrillation, which is an irregular heartbeat that can cause blood to pool and clot in the heart chambers, or endocarditis, which is an infection of the heart valves that can cause pieces of bacteria or tissue to break off and enter the bloodstream.

Hemorrhagic stroke

This is a less common type of stroke, which accounts for about 20% of all strokes. A hemorrhagic stroke is a medical condition characterized by the rupture or leakage of a blood vessel in the brain, resulting in the occurrence of bleeding either within the brain tissue itself or in the surrounding spaces encompassing the brain. It can be further divided into two subtypes:

Intracerebral hemorrhage

This phenomenon happens when a blood vessel located on the outer layer of the brain ruptures, leading to the leakage of blood into the area known as the subarachnoid space, causing bleeding into the brain tissue. Intracerebral hemorrhage is more common in people with high blood pressure, which can weaken the blood vessel walls and make them prone to rupture, or in people with blood disorders, such as hemophilia, which can impair the blood clotting ability and make them prone to bleeding.

Subarachnoid hemorrhage

This occurs when a blood vessel on the surface of the brain bursts, causing bleeding into the subarachnoid space, which is the space between the brain and the skull that is filled with cerebrospinal fluid. Subarachnoid hemorrhage is more common in people with aneurysms, which are bulges or weak spots in the blood vessel walls that can rupture under pressure, or in people with arteriovenous malformations, which are abnormal connections between the arteries and veins in the brain that can cause blood to flow faster and more forcefully, increasing the risk of rupture.

Risk factors and effects of a stroke

Stroke can have various risk factors, which are conditions or behaviors that increase the likelihood of having a stroke. Some risk factors are modifiable, which means they can be changed or controlled, such as high blood pressure, high cholesterol, diabetes, smoking, obesity, physical inactivity, alcohol abuse, or oral contraceptive use.

Some risk factors are non-modifiable, which means they cannot be changed or controlled, such as age, gender, race, ethnicity, family history, or previous stroke. Stroke can be prevented or reduced by identifying and managing the risk factors, as well as by recognizing and treating the warning signs and symptoms of stroke. Some potential symptoms that individuals may experience include a sudden sensation of weakness or numbness that affects either the face, arm, or leg, particularly on just one side of the body. There may also be an abrupt onset of confusion or difficulty in speaking or comprehending information. Additionally, an individual may suddenly encounter challenges with their vision, either in one eye or both. They might also experience difficulties with walking, feeling dizzy, or exhibiting a loss of balance and coordination. Lastly, there is the possibility of a sudden, intense headache that arises without any identifiable cause.

Stroke can have various effects on the brain, depending on the type, severity, and location of the stroke, as well as the extent and duration of the brain damage. The brain can be further divided into four distinct lobes: the frontal lobe, parietal lobe, temporal lobe, and occipital lobe.

Each lobe serves a specific purpose and contributes to various aspects of our cognitive functioning.

• The frontal lobe, located at the front of the brain, is responsible for higher-order thinking skills, decision-making, and personality traits.
• The parietal lobe, situated towards the top and back of the brain, plays a crucial role in sensory processing, spatial awareness, and attention.
• The temporal lobe, found on the sides of the brain, is involved in auditory processing, memory formation, and language comprehension.
• Lastly, the occipital lobe, found at the back of the brain, is primarily responsible for visual processing and interpreting the information received from our eyes.

However, the differences between these hemispheres extend beyond just physical control. On the other hand, the right hemisphere is renowned for its involvement in creativity, imagination, emotional expression, and holistic thinking. It allows us to think outside the box, appreciate art and music, and tap into our intuitive side. This hemisphere excels in recognizing patterns, interpreting emotions, and understanding non-verbal cues.

In fact, each hemisphere also possesses its own unique set of functions and abilities. The left hemisphere is commonly associated with language processing, logical reasoning, analytical thinking, and problem-solving skills. It is the driving force behind our ability to articulate thoughts and engage in rational thought processes, which are responsible for different aspects of cognition, perception, and behavior.

The brain also contains various structures, such as the brainstem, the cerebellum, the thalamus, the hypothalamus, the hippocampus, and the amygdala, which are involved in various functions, like respiration, pulse rate, and hypertension, are vital bodily processes that play significant roles in maintaining overall health and well-being, balance, coordination, movement, sensation, memory, emotion, and hormone regulation. Stroke can affect any part of the brain, causing various impairments and disabilities, such as:

• Motor impairment:

This is the loss or impairment of the ability to move or control the muscles of the body, such as the arms, legs, face, or tongue. Motor impairment can cause weakness, paralysis, spasticity, rigidity, tremor, or involuntary movements. Motor impairment can affect refers to the daily tasks that people typically do, such as getting dressed, eating, bathing, or walking, as well as the quality of life, such as self-esteem, independence, or social participation.

• Sensory impairment

This is the loss or impairment of the ability to perceive or process the sensory information from the body or the environment, such as touch, pain, temperature, pressure, vibration, or position. Sensory impairment can cause numbness, tingling, pain, or reduced or distorted sensation. Sensory impairment can affect the safety and awareness of the body and the surroundings, such as the risk of falls, injuries, or burns, as well as the performance and enjoyment of the activities, such as reading, writing, or playing music.

• Language impairment

This is the loss or impairment of the ability to communicate, as well, as understand the spoken or written words, sentences, or conversations. Language impairment can cause aphasia, which is the difficulty or inability to speak, listen, read, or write, or dysarthria, which is the difficulty or inability to articulate or pronounce the words clearly. Language impairment can affect the expression and comprehension of the thoughts, feelings, needs, or preferences, as well as the social interaction and relationship with others, such as family, friends, or colleagues.

• Cognitive impairment

This is the loss or impairment of the ability to think, reason, learn, remember, or solve problems. Cognitive impairment can cause various deficits, such as attention, concentration, memory, executive function, visuospatial function, or orientation. Cognitive impairment can affect the decision making and judgment, the planning and organization, the initiation and completion, the adaptation and flexibility, or the recognition and identification of the objects, faces, or places, as well as the daily functioning and independence, such as managing finances, medications, or appointments.

Stroke rehabilitation therapies

Rehabilitation therapies are the interventions that aim to improve the function and ability of the stroke survivors, by stimulating the recovery and plasticity of the brain, as well as by compensating and adapting to the impairments and disabilities. These therapies are delivered by various health professionals, such as physiotherapists, occupational therapists, speech and language therapists, and cognitive rehabilitation therapists, who assess the needs and goals of the patients, and design and implement individualized and evidence-based treatment plans.

It can be provided in various settings, such as hospitals, rehabilitation centers, outpatient clinics, home, or community, depending on the availability and accessibility of the resources and services, and the preferences and circumstances of the patients, and classified into four main types:

Physical therapy after stroke

Patient has to work on the motor function and mobility of the stroke survivors, by restoring the strength, range of motion, coordination, balance, and endurance of the affected muscles and joints, as well as by preventing or reducing the complications and secondary problems, such as spasticity, contractures, pain, or pressure ulcers. Such a therapy involves various techniques, such as exercises, stretches, massages, electrical stimulation, ultrasound, or hydrotherapy, as well as various devices, such as braces, splints, orthoses, or prostheses, to assist or facilitate the movement and function of the body. It can help the stroke survivors to regain or improve their ability to perform the activities of daily living, such as walking, standing, sitting, or transferring, as well as to participate in recreational or leisure activities, such as sports, hobbies, or travel.

Occupational therapy

Focuses on improving the functional performance and participation of the stroke survivors, by enhancing the skills, abilities, and strategies to perform the activities of daily living, such as dressing, eating, bathing, toileting, or grooming, as well as the instrumental activities of daily living, such as cooking, cleaning, shopping, or managing finances. Patients, involved in such therapy together with a doctor or rehabilitation staff, learn various techniques, such as task analysis, task modification, task practice, or task feedback, as well as various devices, such as adaptive equipment, assistive technology, or environmental modifications, to enable or facilitate the performance and participation of the stroke survivors.

Step by step, stroke patients learn to regain or improve their independence, autonomy, and quality of life, as well as to cope with the changes and challenges in their roles and routines, such as work, family, or social life.

Speech and language therapy

This is the intervention that focuses on improving the communication and swallowing function of the stroke survivors, by restoring the speech, language, voice, fluency, or resonance of the affected oral and pharyngeal muscles, as well as by preventing or reducing the complications and secondary problems, such as dysphagia, aspiration, or pneumonia. Speech and language therapy can involve various techniques, such as exercises, drills, cues, prompts, or feedback, as well as various devices, such as augmentative and alternative communication, or dysphagia management, to assist or facilitate the communication and swallowing of the stroke survivors.

It helps stroke patients to regain or improve their ability to express and understand the spoken or written language, as well as to eat and drink safely and comfortably, as well as to participate in social and cultural activities, such as conversations, meetings, or events.

Cognitive rehabilitation: brain exercises for stroke recovery

Patients are working on cognitive function and performance of the stroke survivors, by enhancing the attention, memory, executive function, visuospatial function, or orientation of the affected brain regions, as well as by preventing or reducing the complications and secondary problems, such as depression, anxiety, or dementia.

Rehabilitation staff can help you with various techniques, such as training, stimulation, compensation, or adaptation, as well as various devices, such as computer software, mobile applications, or memory aids, to enable or facilitate the cognition and function of the stroke survivors. It may help you to regain or improve their ability to think, reason, learn, remember, or solve problems, as well as to cope with the changes and challenges in their daily living and independence, such as managing finances, medications, or appointments.

Technological interventions

Technological interventions are the applications of various devices, systems, or platforms that use advanced technologies, such as robotics, virtual reality, or wearable devices, to enhance or supplement the rehabilitation therapies for the stroke survivors. Technological interventions can provide various benefits, such as increasing the intensity, frequency, duration, or feedback of the rehabilitation exercises, improving the motivation, engagement, or enjoyment of the rehabilitation activities, or expanding the accessibility, availability, or affordability of the rehabilitation services. Technological interventions can be classified into three main types:

Robot-assisted therapy

Modern robotic devices, such as exoskeletons, end-effectors, or manipulators, to assist or facilitate the movement and function of the affected limbs or body parts of the stroke survivors, and can delivering precise, consistent, and repetitive movements, providing adjustable levels of assistance or resistance, measuring the performance and progress of the stroke survivors, or offering interactive and adaptive environments and scenarios. As a stroke patient, you learn to improve your motor function and mobility, such as the range of motion, strength, coordination, or balance of the upper or lower extremities, as well as to reduce the spasticity, pain, or fatigue of the affected muscles and joints.

Virtual reality training

Modern times offer modern technologies, such as virtual reality devices, such as head-mounted displays, gloves, or joysticks, to immerse the stroke survivors in a simulated or augmented reality environment, where they can perform various tasks or activities that mimic the real-world situations or challenges. Such an amazing technology can provide various advantages, such as enhancing the sensory and motor stimulation, providing immediate and multisensory feedback, increasing the motivation and engagement of the stroke survivors, or offering customized and realistic environments and scenarios.

Wearable devices

It’s where wearable devices, such as sensors, electrodes, or stimulators are used, to monitor, measure, or modulate the physiological or neurological signals or responses of the stroke survivors. They can enable the continuous and remote assessment, intervention, and evaluation of the stroke survivors, providing real-time and objective data and feedback, increasing the convenience and comfort of the stroke survivors, or offering personalized and adaptive settings and modes. If you lost some physical abilities after stroke, such devices may help you to improve communication and swallowing function, such as the speech, language, voice, fluency, or resonance of the affected oral and pharyngeal muscles, as a whole it affects emotional and psychological well-being, such as the mood, affect, or stress.

Medication and stroke recovery

Medication is an important component of stroke recovery, as it can help prevent or treat the complications and secondary problems that may arise after stroke, as well as enhance the effects of the rehabilitation therapies. Medication can be classified into three main types:

Anticoagulants after stroke

These are drugs that prevent or reduce the formation of blood clots, which can cause ischemic stroke or embolic stroke. Anticoagulants can be given orally, such as warfarin, dabigatran, rivaroxaban, apixaban, or edoxaban, or intravenously, such as heparin or enoxaparin. Anticoagulants prevent recurrent stroke, especially in patients with atrial fibrillation, which is an irregular heartbeat that can cause blood clots in the heart.

Such medicine also are used to treat acute ischemic stroke, especially in patients with large vessel occlusion, which is a blockage of a major artery in the brain. Anticoagulants can have side effects, such as bleeding, bruising, or allergic reactions, and require regular monitoring of the blood clotting time and the dosage adjustment.

Neuroprotective agents

These are drugs that protect or enhance the survival and function of the brain cells, by reducing the damage caused by the lack of blood flow and oxygen, or by stimulating the recovery and plasticity of the brain. These medications include various substances, such as antioxidants, anti-inflammatory agents, growth factors, or neurotransmitters. Neuroprotective agents can help treat acute ischemic stroke, especially in patients who receive thrombolytic therapy, which is the administration of a clot-busting drug, such as alteplase, within 4.5 hours of the onset of stroke symptoms. Neuroprotective agents can also help improve the long-term outcomes of stroke, such as the cognitive and motor function, the quality of life, and the survival rate. Neuroprotective agents are still under investigation, and their efficacy and safety are not yet fully established.

Spasticity management

These are drugs that reduce or relieve the spasticity, which is the abnormal increase in muscle tone or stiffness, that can affect the movement and function of the affected limbs or body parts after stroke. Spasticity management can include various drugs, such as baclofen, tizanidine, dantrolene, or botulinum toxin. Treatment of spastic muscles  helps to improve the motor function and mobility of the stroke survivors, by increasing the range of motion, reducing the pain, or preventing the contractures, which are the permanent shortening of the muscles or tendons. The effects of the physical therapy and the occupational therapy can be enhanced, by facilitating the exercises, stretches, or massages. Spasticity management can have side effects, such as drowsiness, weakness, nausea, or headache, and require careful dosing and monitoring.

Nutrition and lifestyle after stroke

Nutrition and lifestyle are essential factors for stroke recovery, as they can help prevent or manage the risk factors and complications of stroke, as well as support the effects of the rehabilitation therapies. Nutrition and lifestyle can be improved by making some simple and healthy changes, such as:

Dietary modifications after stroke

Eating a balanced and nutritious diet can help lower the blood pressure, cholesterol, and blood sugar levels, which are the main risk factors for stroke. A healthy diet can also provide the essential nutrients, such as vitamins, minerals, antioxidants, and omega-3 fatty acids, that can help protect and repair the brain cells, as well as reduce the inflammation and oxidative stress.

Include in your daily meal various foods, such as fruits, vegetables, whole grains, lean protein, low-fat dairy, nuts, seeds, and fish, and can limit or avoid foods that are high in salt, sugar, saturated fat, or trans fat, such as processed, fast foods, baked goods or heavy fried vegetables and meat. Try out Mediterranean diet, the DASH diet, or the MIND diet, which have been shown to reduce the risk of stroke and improve the cognitive function.

Physical activity after stroke

Engaging in regular and moderate physical activity can help improve the cardiovascular and metabolic health, which can prevent or reduce the risk of stroke and its recurrence. Physical activity can also help improve the physical and mental function, by enhancing the strength, endurance, balance, coordination, mood, and cognition of the stroke survivors. Depending on your condition, try exercises, such as aerobic, resistance, or flexibility exercises, and can be tailored to the individual needs and abilities of the stroke survivors, depending on their age, health, and preferences.

Do not forget that it is important to move as much as you can and make it your daily routine, such as walking, gardening, or household chores, or can be enjoyed as a recreational or leisure activity, such as dancing, swimming, or cycling. Do it at least 150 minutes per week, or 30 minutes per day, at a moderate intensity, or as recommended by the health professionals.

Smoking and alcohol cessation

Quitting smoking and limiting alcohol consumption can help lower the risk of stroke and its complications, as well as improve the overall health and well-being of the stroke survivors. Smoking can damage the blood vessels and increase the blood pressure, cholesterol, and clotting factors, which can cause or worsen ischemic stroke or hemorrhagic stroke.

Smoking can also impair the oxygen delivery and the brain function, as well as interfere with the effects of the medication and the rehabilitation therapies.

Alcohol can also damage the blood vessels and increase the blood pressure, as well as affect the blood sugar and the electrolyte levels, which can cause or worsen your stroke condition.

Depression after stroke

Depression is common following stroke; the mood disorder can be an emotional reaction to the sudden and devastating change in the patients’ lives and independence.

Depression after stroke is also an organic consequence of the brain injury. Severe depression is more common with strokes in the dominant hemisphere. Less commonly, stroke can cause mania. Depression can hamper recovery from the stroke and limit the efficacy of rehabilitation.

Both counseling and the use of antidepressant medications often are needed. Antidepressant medications, either tricyclic drugs or serotonin agonists, in particular, are helpful. While major tranquilizers, such as haloperidol, may slow recovery from a stroke, some reports suggest that amphetamines may potentiate recovery.

Discharge Planning

In an era of managed care, plans for management after discharge from the acute-care setting should begin as soon as the patients are medically stable.

Most institutions have a care manager/discharge planner who can provide assistance in arranging for continued treatment after hospitalization. The goal should be to provide continued long-term medical treatment and rehabilitation that meets the patients’ and families’ wishes and needs.