Stroke Rehabilitation

	Overview
	Health Tools
	What to Expect After a Stroke
	Concerns of the Caregiver
	Preventing Another Stroke
	Medications for Stroke Prevention
	Medications for Stroke Rehabilitation
	Adapting After a Stroke
	Other Places To Get Help
	Related Information
	References
	Credits

Is this topic for you?

This topic covers rehabilitation after a stroke. For information on stroke itself, see the topic Stroke.

What is stroke rehabilitation?

The best way to get better after a stroke is to start stroke rehabilitation (“rehab”). In stroke rehab, a team of health professionals works with you to regain skills you lost as the result of a stroke. Rehab can help you to:

• Do as well and be as independent as possible.
• Learn to live with the changes to your brain and body caused by the stroke.
• Adjust to living within your home, family, and community.

Rehab starts while you are still in the hospital. After you leave the hospital, you can continue treatment at a rehab center or at home. Most rehab programs offer at least 3 hours of therapy a day, 5 or 6 days a week.

A key part of rehab is taking steps to prevent a future stroke. To stay in good health, you may need to take medicines and make some lifestyle changes. Work with your rehab team to decide what type of exercise, diet, or other lifestyle choices are best for you.

You have the greatest chance of regaining your abilities during the first few months after a stroke. So it is important to start rehab soon after a stroke and do a little every day.

Who is on a stroke rehab team?

A team of health professionals will work together to help you recover from a stroke. A rehab team may include doctors and nurses who specialize in stroke rehab, as well as rehabilitation therapists such as:

• A physical therapist to work on problems with movement, balance, and coordination.
• An occupational therapist to help you practice eating, bathing, dressing, and writing, and other daily tasks.
• A speech-language therapist to help you relearn language skills and also help if you have problems with swallowing.
• A recreational therapist to help you return to activities that you enjoyed before the stroke.
• A psychologist or counselor to help you deal with your emotions.
• Other health professionals, such as a dietitian to help you plan a healthy diet and a vocational counselor to help you find a job or get back to work.

What kinds of problems can people have after a stroke?

The problems you have after a stroke depend on what part of your brain was affected and how much damage the stroke caused. People who have had a stroke often have:

• Problems with movement and sensation. You may have pain, numbness, or tingling in your arms and legs; muscle stiffness or spasms; weakness; and trouble with walking and moving. You may have problems with your sense of touch or how well you feel hot and cold, trouble swallowing and eating, and urinary or bowel problems.
• Problems seeing things on one side of the body. If you do not turn your head to that side, you may forget or ignore that side of your body.
• Problems with language and thinking. You may not be able to understand written or spoken language, read or write, or express your thoughts. You may also have problems with memory and learning.
• Emotional problems. A stroke can cause feelings of fear, anxiety, anger, sadness, and grief, both for survivors of a stroke and their loved ones.

Does a stroke cause permanent problems?

A stroke damages parts of the brain that control different things in the body, such as speech and movement. But other parts of the brain can take over for the damaged areas. Many people are able to get back most of the skills and abilities they lost.

Some people do have permanent problems after a stroke. But more than half of people who have a stroke regain their ability to take care of themselves.¹

How long does rehab take?

For most people, rehab is a lifelong process. The road to recovery can be long and frustrating, so keeping a positive outlook is key. Try everything you can to get better, and get relief from pain if you need to. Your stroke rehab team is there to help in as many ways as it can. A strong support network of family and friends is also very important.

You may recover the most in the first few weeks or months after your stroke. But you can keep getting better for years. It just may happen more slowly. And it may take a long time and a lot of hard work. Don't give up hope.

What else should you think about?

• It is common to feel sad and hopeless after a stroke. It may be hard to deal with your emotions. Tell your rehab team how you feel. Get treatment for depression if you need it.
• It is important to get the support you need. Let your loved ones help you. Get them involved in your treatment. Talk to others who have had a stroke, and find out how they handled problems.
• A stroke affects your loved ones too. They may be as scared and worried as you are. Urge them to find a caregiver support group and learn ways to relieve their stress.
• Medical insurance may not cover rehab or devices you need after you leave the hospital. Have a caregiver check on Medicare or other programs.

Frequently Asked Questions

Health tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I put my loved one who has had a stroke in a nursing home?
	Actionsets are designed to help people take an active role in managing a health condition.
	Managing eating problems after a stroke

Initial disabilities

Your disabilities and your ability to get better after a stroke depend on:

• Which side of the brain was affected (whether it is your dominant side).
• Which part of the brain was damaged by the stroke.
• How much of the brain was damaged.
• Your general health before the stroke.

Impairments after a stroke may include problems with muscles and movement. These include:

• Weakness on one side of the body. This may cause you to have trouble walking, grasping objects, or doing other tasks. The side of the body that is affected is opposite from the side of the brain that was damaged by the stroke.
• Joint pain and rigidity. A person with a very weak arm may have shoulder pain caused by a tight or locked-up joint. Movement of the joint is essential to keep it from "freezing" and to make sure that you can move it easily when your strength returns.
• Muscle stiffness or spasms (spasticity). You may need certain medicines or injections of substances that block nerve reactions. For more information, see treatment for stroke-related spasticity.
• Problems with your sense of touch or your ability to feel hot and cold. You may also have problems judging the position of parts of your body.
• Pain, numbness, or tingling in your limbs.
• Trouble with walking and coordinating body movements.
• Problems swallowing and eating (dysphagia). For more information, see dysphagia. See also:

  Managing eating problems after a stroke.

• Urinary or bowel problems. You may have trouble holding your urine (urinary incontinence) or trouble emptying your bladder (urinary retention). Or you may have constipation or problems controlling bowel movements. Although this can make you feel embarrassed or discouraged, these issues are usually not permanent. For more information, see how to manage bladder and bowel problems after a stroke.

Other problems involve how you process information and your emotions. These include:

• Speech and language problems (aphasia). Aphasia usually results from damage to the left side of the brain, which is the area responsible for language. Some people who have aphasia may not be able to understand written or spoken language, read or write, or express their own thoughts. For information on coping with communication problems, see how to manage speech and language problems after a stroke.
• Memory and cognitive problems. You may have damage to parts of your brain that control awareness, learning, and memory. You may have trouble focusing or remembering. It may be difficult to make plans, learn new activities, or do other complex tasks. You may not be able to acknowledge the physical impairments caused by your stroke. For more information, see memory problems, changes in speed of action, and changes in judgment after a stroke.
• Problems with perception. You may have trouble judging distance, size, position, rate of movement, form, and how parts relate to the whole. For more information, see changes in perception after a stroke.
• Problems recognizing your affected side. After a stroke, some people have problems seeing to one side. For example, people with right-sided paralysis may have trouble seeing to the right. Most people learn to adjust by turning their head toward their affected side. If you do not turn your head to the affected side, you may forget or ignore that side of your body. Some people have trouble recognizing body parts on the affected side. This is especially true for people who do not have feeling in the affected arm or leg.
  • You may recognize objects on the unaffected side of your body but not on the affected side. Some people may see objects and not be able to attach a meaning to them. For example, you may examine a fork curiously without remembering how to use it for eating.
  • Objects may look closer or farther away than they really are. You may notice this more when you are eating or dressing, or you may bump into furniture.
  For more information, see problems from neglecting the affected side of the body after a stroke.
• Emotional problems. Fear, anxiety, anger, sadness, frustration, and grief are common after a stroke. About one-third of people older than 65 who have had a stroke have symptoms of depression.¹ Depression is a serious condition that requires treatment. For more information, see changes in emotions and recognizing and dealing with depression after a stroke.

Recovering what was lost—The first steps

The brain is a remarkable organ that has the ability to rewire itself to some degree. Parts of the brain that have not been affected by the stroke may be able to take over for the damaged areas, performing some of the tasks formerly controlled by the affected areas.

Much of your improvement in motor functioning—walking, using your arms and legs—comes in the early phase of stroke recovery. This is one of the reasons that it is so important to start rehabilitation as soon as possible.

Your first stage of rehab usually begins 24 to 48 hours after your stroke, as soon as you are stable and while you are in the hospital. For most people, rehab begins with the goal of getting out of bed and into a chair. As you gradually regain strength and function, nurses or therapists will help you regain skills and relearn tasks that were lost because of the stroke. The intensity and focus of initial rehab will vary with each person. It is a process based on your own needs. If you have other health problems (such as a heart condition, for example), you may need to go a bit slower than someone who was healthy before his or her stroke.

When you are ready for more intense therapy, your treatment may continue at a rehab facility. This may be in another part of the hospital where you were first treated, at a separate facility, or at home if it is safe for you and you have the right support. You may go to a skilled nursing facility if you are not well enough for a more intense program. Or a nursing home may be the best place for your rehab to continue. Studies show that people who have the greatest desire to improve and who have a good support network of friends and family will improve the most with rehab, regardless of where the rehab takes place.²

Recovering from a stroke can be very frustrating. It is common to face depression and have occasional setbacks. You may make strong improvement at first and then feel like you have lost some of what you gained. Overcoming problems with speech and language may seem very slow, because it may be difficult for you to measure your progress. You may feel a deep sense of grief for the loss of an active lifestyle prior to your stroke. But your stroke rehab team is there to help in as many ways as possible. Discussing your frustrations with the team and your family will be an important part of your recovery.

A lifelong process

For most people who have had a stroke, rehab is a lifelong process that also includes medicines—such as daily aspirin—and lifestyle changes to improve overall health and prevent future strokes. Controlling other risk factors for stroke, such as high blood pressure, will also be important.

Establishing a network of support outside your family may be helpful. Stroke support groups may be offered through your local chapter of the American Stroke Association (a division of the American Heart Association) or the National Stroke Association. These will include people who are learning to cope with many of the same things that you and your family are facing. Loved ones who help take care of you will also benefit from support networks.

Taking care of a loved one who has had a stroke can be difficult for many reasons. You may be afraid that your loved one will have another stroke or will not be able to accept or overcome disabilities. You may worry that you are not prepared to care for someone who has just had a stroke, or you may have your own health concerns that make it difficult for you to care for another person. You may also become depressed over losing the lifestyle that you previously enjoyed with your loved one. And you may worry about the costs of rehabilitation and a loss of income.

Before your loved one returns home, the rehab team will train you or other family members to help with therapy. You may learn to help your loved one get up from a fall, get dressed, get to the bathroom, eat, and do other activities. If you have your own health concerns that prevent you from being able to help, you may need in-home help, or your loved one may need to go to a nursing home or assisted-living facility. But even if you can't provide physical help, your love and support are still key to your loved one's recovery.

Here are ways that you can help with your loved one's recovery:

• Give support and encouragement for participation in the rehab program.
• Visit and talk with your loved one often. Play cards together or watch TV. Try to keep in touch with your loved one's friends as much as possible, and encourage them to visit.
• Participate in educational programs and attend rehab sessions as much as possible.
• Help your loved one learn and practice new skills.
• Find out what your loved one can do independently or needs help with. Avoid doing things for your loved one that he or she is able to do without help.

You will also need to take care of your own well-being.

• Eat well, get enough rest, and take time to do things that you enjoy. Get out of the house as much as possible.
• Make sure that you do not ignore your own health while you are caring for your loved one. Do not try to do everything yourself. Keep up with your own doctor visits and make sure to take your own medicines regularly. Ask other family members to help. Find out if you qualify for adult day care or for home health care visits to help with rehab.
• Locate a support group to attend. You can find them through local chapters of the American Stroke Association (a division of the American Heart Association) or the National Stroke Association. Also, check with the rehab team for recommendations. They may be able to offer advice about insurance coverage as well.
• Schedule time for yourself. Get out of the house and do things that you enjoy, run errands, or go shopping.

For more information on caregiving, see the topic Caregiver Tips.

Should I put my loved one in a nursing home?

There are several factors you cannot change that increase your risk of stroke. But there are also several things you have some control over that can help you avoid another stroke, including:

• High blood pressure.
• Heart disease.
• High cholesterol.
• Diabetes.
• Obesity.
• Excessive use of alcohol.
• Use of tobacco products.
• Too much caffeine.
• Use of certain illegal drugs, such as cocaine.

To prevent another stroke and to maintain good health, you may need to take medicines, and you may need to make lifestyle changes. These changes may include:

• Getting regular exercise that increases your breathing and your heartbeat.
• Limiting your intake of caffeine, animal fats, sugars, and processed foods and eating plenty of fruits, vegetables, and high-fiber foods.
• Quitting the use of tobacco products.
• Limiting your alcohol consumption.

These simple steps may help you live a longer, healthier life. It is never too late to enjoy the benefits of healthy lifestyle choices. They can reduce your risk for another stroke and can also help prevent a heart attack and many other health problems. Talk with your doctor or other members of your rehab team to determine what type of exercise, diet, or other lifestyle choices are best for you.

If you or your loved one has already had a stroke, you need to watch carefully for symptoms of another stroke. Immediate medical attention and treatment with t-PA (tissue plasmogen activator) within 3 hours may help prevent or reduce permanent brain damage. If signs of a stroke develop suddenly, call 911 or other emergency services immediately. For more information on stroke symptoms and when to seek medical attention, see the topic Stroke.

After a stroke and during rehabilitation, you need medicines to help prevent another stroke. You may need medicines to thin your blood and prevent clots from forming and medicines to lower blood pressure and cholesterol.

Antiplatelets to prevent clots

Aspirin, aspirin with extended-release dipyridamole (Aggrenox), and clopidogrel (Plavix)

Anticoagulants to keep clots from growing and to prevent new clots

Anticoagulants for stroke

Cholesterol-lowering medicines

Statins to lower cholesterol

Zetia, a new cholesterol-lowering medicine

Niacin

Blood pressure-lowering medicines

Angiotensin-converting enzyme (ACE) inhibitors

Angiotensin II receptor blockers (ARBs)

Beta-blockers

Diuretics

After a stroke, you may need medicines to decrease pain, treat depression, or help speed your recovery. These may include:

• Medicines for pain and depression after a stroke. Examples are:
  • Selective serotonin reuptake inhibitors (SSRIs) for pain and depression.
  • Tricyclic antidepressants for pain and depression.
  • Anticonvulsant medicines for pain.
• Medicines for sleeping. After a stroke, you may have trouble sleeping (insomnia). Your doctor may prescribe different types of medicines to help you sleep, including the antidepressants trazodone (Desyrel) and mirtazapine (Remeron), which have sedation as a side effect. Other sleep medicines, such as chloral hydrate, may be effective but have the potential for addiction.
• Medicines for anxiety. Various medicines may be used to treat anxiety after a stroke. Benzodiazepines, such as lorazepam (Ativan, for example), are minor tranquilizers or sedatives that slow down the central nervous system. Benzodiazepines are sometimes used to treat seizures as well. Alprazolam (Xanax) and buspirone (BuSpar) are antianxiety medicines that relieve anxiety and nervousness.
• Medicines for agitation. Doctors use various types of medicines to treat agitation. Neuroleptics, such as haloperidol (Haldol), risperidone (Risperdal), and olanzapine (Zyprexa), are antipsychotic medicines that work by changing the effects of brain chemicals. The anticonvulsant valproic acid is sometimes used to treat agitation.
• Methylphenidate to improve mood and speed recovery. This medicine is sometimes used for a short time in the first stages of rehab.
• Dextroamphetamine to improve attention span and help learning and memory. Experts are still researching the benefits and risks of this drug for people who have had a stroke.

Also see treatment (including medicines) for spasticity.

After a stroke, rehabilitation will not only focus on helping you recover from disabilities but also on making changes in your lifestyle, at home, at work, and in relationships. Changes will depend on the type of disabilities, which are determined by the part of your brain that was affected by the stroke.

A stroke in the right side of the brain can cause difficulty with performing everyday tasks. This type of stroke affects the ability to judge distance, size, position, rate of movement, form, and the way parts relate to the whole.

Perception problems may include:

• Not noticing people or things on the affected side and turning your head or eyes to the unaffected side. Someone with these types of problems may not be able to steer a wheelchair through a large doorway without bumping the door frame.
• Not being aware of body parts on the affected side.
• Having difficulty forming numbers and letters, confusing similar numbers, or not being able to add numbers.
• Having trouble spelling words and reading.
• Confusing the inside and outside of clothing or the right and left sides of clothing.
• Having a hard time perceiving whether you are sitting or standing.

People with perception problems—even minor ones—should not drive a car. A stroke can also affect mobility, communication, vision, and decision-making, all skills that are needed for driving.

Some tips for working with someone who has perception problems include the following:

• Cut down on clutter to prevent a fall. Also, make sure that rooms are well lit. Put night lights in the bedroom and bathroom.
• Mark lines on door frames or full-length mirrors so that the person can see what is vertical.
• Do not overestimate the person's abilities. Watch to see what can be done safely.
• If your loved one has trouble performing a task, be patient, and walk him or her through the steps.

People who have had a stroke tend to be slow, cautious, and disorganized when they are doing unfamiliar activities. They appear anxious and hesitant, which is often quite different from the way they were before the stroke.

Depending on the amount of disability, many people may need help at home with a variety of daily activities. For more information, see:

Managing eating problems after a stroke.

Also see:

• Managing bowel and bladder problems.
• Managing memory problems.
• Getting dressed.
• Preventing falls.
• Preventing injury to affected limbs.
• Preventing sores and stiff joints.
• Managing swelling in an affected arm or leg.
• Driving a car after a stroke.

Online Resource

Organizations

• Depression
• High Blood Pressure (Hypertension)
• High Cholesterol
• Stroke
• Transient Ischemic Attack (TIA)

Citations

1. American Heart Association (2007). Heart disease and stroke statistics—2007 update. Circulation, 115(5): e69–e171. Also available online: http://www.americanheart.org/presenter.jhtml?identifier=1928.

2. Brandstarter ME (2005). Stroke rehabilitation. In JA DeLisa et al., eds., Physical Medicine and Rehabilitation: Principles and Practice, 4th ed., vol. 2, pp. 1655–1676. Philadelphia: Lippincott Williams and Wilkins.

Other Works Consulted

• Bates B, et al. (2005). Veterans Affairs/Department of Defense clinical practice guideline for the management of adult stroke rehabilitation care: Executive summary. Stroke, 36(9): 2049–2056.

• Duncan PW, et al. (2005). Management of adult stroke rehabilitation care: A clinical practice guideline. Stroke, 36: e100–e143.

• Finestone HM, Greene-Finestone LS (2003). Rehabilitation medicine: 2. Diagnosis of dysphagia and its nutritional management for stroke patients. Canadian Medical Association Journal, 169(10): 1041–1044.

• Kaplan PE, et al. (2003). Rehabilitation of Stroke. Burlington, MA: Butterworth–Heinemann.

• Kasner SE, Morgenstern LB (2004). Cerebrovascular disorders. IN DC Dale, DD Federman, eds., ACP Medicine, section 11, chap. 4. New York: WebMD.

• Studenski S, Brown CJ (2004). Rehabilitation of geriatric patients. In DC Dale, DD Federman, eds., Scientific American Medicine, section 8, chap. 10. New York: WebMD.