Post-Stroke

Rehabilitation

U.S. DEPARTMENT OF HEALTH

AND HUMAN SERVICES
Public Health Service
National Institutes of Health
Post-Stroke Rehabilitation

I
n the United States more than 700,000 people
suffer a stroke* each year and approximately
two-thirds of these individuals survive and
require rehabilitation. The goals of rehabili­
tation are to help survivors become as inde­
pendent as possible and to attain the best
possible quality of life. Even though rehabili­
tation does not “cure” the effects of stroke
in that it does not reverse brain damage,
rehabilitation can substantially help people
achieve the best possible long-term outcome.

What is post-stroke rehabilitation?

R
ehabilitation helps stroke survivors
relearn skills that are lost when part
of the brain is damaged. For example, these
skills can include coordinating leg movements
in order to walk or carrying out the steps
involved in any complex activity. Rehabili­
tation also teaches survivors new ways of
performing tasks to circumvent or compen­
sate for any residual disabilities. Individuals
may need to learn how to bathe and dress
using only one hand, or how to communicate

* An ischemic stroke or “brain attack” occurs when

brain cells die because of inadequate blood flow.
When blood flow is interrupted, brain cells are
robbed of vital supplies of oxygen and nutrients.
About 80 percent of strokes are caused by the
blockage of an artery in the neck or brain. A hemor­
rhagic stroke is caused by a burst blood vessel in the
brain that causes bleeding into or around the brain.

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effectively when their ability to use language
has been compromised. There is a strong con­
sensus among rehabilitation experts that the
most important element in any rehabilitation
program is carefully directed, well-focused,
repetitive practice—the same kind of practice
used by all people when they learn a new skill,
such as playing the piano or pitching a baseball.

Rehabilitative therapy begins in the acute-

care hospital after the person’s overall
condition has been stabilized, often within
24 to 48 hours after the stroke. The first steps
involve promoting independent movement
because many individuals are paralyzed or
seriously weakened. Patients are prompted
to change positions frequently while lying in
bed and to engage in passive or active range-
of-motion exercises to strengthen their stroke-
impaired limbs. (“Passive” range-of-motion
exercises are those in which the therapist
actively helps the patient move a limb
repeatedly, whereas “active” exercises are
performed by the patient with no physical
assistance from the therapist.) Depending
on many factors—including the extent of the
initial injury—patients may progress from
sitting up and being moved between the bed
and a chair to standing, bearing their own
weight, and walking, with or without assis­
tance. Rehabilitation nurses and therapists
help patients who are able to perform progres­
sively more complex and demanding tasks,
such as bathing, dressing, and using a toilet,
and they encourage patients to begin using
their stroke-impaired limbs while engaging
in those tasks. Beginning to reacquire the
ability to carry out these basic activities of

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daily living represents the first stage in a
stroke survivor’s return to independence.

For some stroke survivors, rehabilitation will

be an ongoing process to maintain and refine
skills and could involve working with special­
ists for months or years after the stroke.

What disabilities can result from a stroke?

T
he types and degrees of disability that
follow a stroke depend upon which area
of the brain is damaged and how much is
damaged. It is difficult to compare one
individual’s disability to another, since
every stroke can damage slightly different
parts and amounts of the brain. Generally,
stroke can cause five types of disabilities:
paralysis or problems controlling move­
ment; sensory disturbances including pain;
problems using or understanding language;
problems with thinking and memory; and
emotional disturbances.

Paralysis or problems controlling movement

(motor control)

Paralysis is one of the most common disabili­

ties resulting from stroke. The paralysis is
usually on the side of the body opposite the
side of the brain damaged by stroke, and may
affect the face, an arm, a leg, or the entire
side of the body. This one-sided paralysis
is called hemiplegia if it involves complete
inability to move or hemiparesis if it is less
than total weakness. Stroke patients with
hemiparesis or hemiplegia may have diffi­
culty with everyday activities such as walk­
ing or grasping objects. Some stroke patients

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have problems with swallowing, called
dysphagia, due to damage to the part of the
brain that controls the muscles for swallow­
ing. Damage to a lower part of the brain, the
cerebellum, can affect the body’s ability to
coordinate movement—a disability called
ataxia—leading to problems with body
posture, walking, and balance.

Sensory disturbances including pain

Stroke patients may lose the ability to feel

touch, pain, temperature, or position. Sensory
deficits also may hinder the ability to recognize
objects that patients are holding and can even
be severe enough to cause loss of recognition
of one’s own limb. Some stroke patients expe­
rience pain, numbness, or odd sensations of
tingling or prickling in paralyzed or weakened
limbs—a symptom known as paresthesias.

The loss of urinary continence is fairly common

immediately after a stroke and often results
from a combination of sensory and motor
deficits. Stroke survivors may lose the ability
to sense the need to urinate or the ability
to control bladder muscles. Some may lack
enough mobility to reach a toilet in time.
Loss of bowel control or constipation also
may occur. Permanent incontinence after a
stroke is uncommon, but even a temporary
loss of bowel or bladder control can be
emotionally difficult for stroke survivors.

Stroke survivors frequently have a variety

of chronic pain syndromes resulting from
stroke-induced damage to the nervous system
(neuropathic pain). In some stroke patients,
pathways for sensation in the brain are

4
damaged, causing the transmission of false
signals that result in the sensation of pain
in a limb or side of the body that has the
sensory deficit. The most common of these
pain syndromes is called “thalamic pain
syndrome” (caused by a stroke to the thala­
mus, which processes sensory information
from the body to the brain), which can be
difficult to treat even with medications.
Finally, some pain that occurs after stroke
is not due to nervous system damage, but
rather to mechanical problems caused by
the weakness from the stroke. Patients who
have a seriously weakened or paralyzed arm
commonly experience moderate to severe
pain that radiates outward from the shoulder.
Most often, the pain results from lack of
movement in a joint that has been immobi­
lized for a prolonged period of time (such
as having your arm or shoulder in a cast for
weeks) and the tendons and ligaments around
the joint become fixed in one position. This is
commonly called a “frozen” joint; “passive”
movement (the joint is gently moved or flexed
by a therapist or caregiver rather than by the
individual) at the joint in a paralyzed limb
is essential to prevent painful “freezing”
and to allow easy movement if and when
voluntary motor strength returns.

Problems using or understanding

language (aphasia)

At least one-fourth of all stroke survivors

experience language impairments, involving
the ability to speak, write, and understand
spoken and written language. A stroke-induced
injury to any of the brain’s language-control

5
centers can severely impair verbal communi­
cation. The dominant centers for language are
in the left side of the brain for right-handed
individuals and many left-handers as well.
Damage to a language center located on the
dominant side of the brain, known as Broca’s
area, causes expressive aphasia. People with
this type of aphasia have difficulty convey­
ing their thoughts through words or writing.
They lose the ability to speak the words they
are thinking and to put words together in
coherent, grammatically correct sentences.
In contrast, damage to a language center
located in a rear portion of the brain, called
Wernicke’s area, results in receptive aphasia.
People with this condition have difficulty
understanding spoken or written language
and often have incoherent speech. Although
they can form grammatically correct sen­
tences, their utterances are often devoid of
meaning. The most severe form of aphasia,
global aphasia, is caused by extensive damage
to several areas of the brain involved in
language function. People with global
aphasia lose nearly all their linguistic
abilities; they cannot understand language
or use it to convey thought.

Problems with thinking and memory

Stroke can cause damage to parts of the brain

responsible for memory, learning, and aware­
ness. Stroke survivors may have dramatically
shortened attention spans or may experience
deficits in short-term memory. Individuals
also may lose their ability to make plans,
comprehend meaning, learn new tasks, or
engage in other complex mental activities.

6
Two fairly common deficits resulting from
stroke are anosognosia, an inability to
acknowledge the reality of the physical
impairments resulting from stroke, and
neglect, the loss of the ability to respond to
objects or sensory stimuli located on the
stroke-impaired side. Stroke survivors who
develop apraxia (loss of ability to carry out
a learned purposeful movement) cannot
plan the steps involved in a complex task
and act on them in the proper sequence.
Stroke survivors with apraxia also may
have problems following a set of instructions.
Apraxia appears to be caused by a disruption
of the subtle connections that exist between
thought and action.

Emotional disturbances

Many people who survive a stroke feel fear,

anxiety, frustration, anger, sadness, and a
sense of grief for their physical and mental
losses. These feelings are a natural response
to the psychological trauma of stroke. Some
emotional disturbances and personality
changes are caused by the physical effects
of brain damage. Clinical depression, which
is a sense of hopelessness that disrupts an
individual’s ability to function, appears to
be the emotional disorder most commonly
experienced by stroke survivors. Signs of
clinical depression include sleep disturbances,
a radical change in eating patterns that may
lead to sudden weight loss or gain, lethargy,
social withdrawal, irritability, fatigue, self-
loathing, and suicidal thoughts. Post-stroke
depression can be treated with antidepressant
medications and psychological counseling.

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What medical professionals specialize in
post-stroke rehabilitation?

P
ost-stroke rehabilitation involves physi­
cians; rehabilitation nurses; physical,
occupational, recreational, speech-language,
and vocational therapists; and mental
health professionals.

Physicians

Physicians have the primary responsibility

for managing and coordinating the long-term
care of stroke survivors, including recom­
mending which rehabilitation programs will
best address individual needs. Physicians also
are responsible for caring for the stroke survi­
vor’s general health and providing guidance
aimed at preventing a second stroke, such as
controlling high blood pressure or diabetes
and eliminating risk factors such as cigarette
smoking, excessive weight, a high-cholesterol
diet, and high alcohol consumption.

Neurologists usually lead acute-care stroke

teams and direct patient care during hospi­
talization. They sometimes participate on the
long-term rehabilitation team. Other subspe­
cialists often lead the rehabilitation stage of
care, especially physiatrists, who specialize
in physical medicine and rehabilitation.

Rehabilitation nurses

Nurses specializing in rehabilitation help

survivors relearn how to carry out the basic
activities of daily living. They also educate
survivors about routine health care, such as
how to follow a medication schedule, how to
care for the skin, how to move out of a bed

8
and into a wheelchair, and special needs for
people with diabetes. Rehabilitation nurses
also work with survivors to reduce risk factors
that may lead to a second stroke, and provide
training for caregivers.

Nurses are closely involved in helping stroke

survivors manage personal care issues, such
as bathing and controlling incontinence.
Most stroke survivors regain their ability
to maintain continence, often with the help
of strategies learned during rehabilitation.
These strategies include strengthening pelvic
muscles through special exercises and follow­
ing a timed voiding schedule. If problems
with incontinence continue, nurses can help
caregivers learn to insert and manage cath­
eters and to take special hygienic measures
to prevent other incontinence-related health
problems from developing.

Physical therapists

Physical therapists specialize in treating

disabilities related to motor and sensory
impairments. They are trained in all aspects
of anatomy and physiology related to normal
function, with an emphasis on movement.
They assess the stroke survivor’s strength,
endurance, range of motion, gait abnormalities,
and sensory deficits to design individualized
rehabilitation programs aimed at regaining
control over motor functions.

Physical therapists help survivors regain the use

of stroke-impaired limbs, teach compensatory
strategies to reduce the effect of remaining
deficits, and establish ongoing exercise pro­
grams to help people retain their newly learned

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skills. Disabled people tend to avoid using
impaired limbs, a behavior called learned
non-use. However, the repetitive use of
impaired limbs encourages brain plasticity**
and helps reduce disabilities.

Strategies used by physical therapists to

encourage the use of impaired limbs include
selective sensory stimulation such as tapping
or stroking, active and passive range-of-motion
exercises, and temporary restraint of healthy
limbs while practicing motor tasks.

In general, physical therapy emphasizes

practicing isolated movements, repeatedly
changing from one kind of movement to
another, and rehearsing complex movements
that require a great deal of coordination and
balance, such as walking up or down stairs
or moving safely between obstacles. People
too weak to bear their own weight can still
practice repetitive movements during hydro­
therapy (in which water provides sensory
stimulation as well as weight support) or
while being partially supported by a harness.
A recent trend in physical therapy emphasizes
the effectiveness of engaging in goal-directed
activities, such as playing games, to promote
coordination. Physical therapists frequently
employ selective sensory stimulation to
encourage use of impaired limbs and to help
survivors with neglect regain awareness of
stimuli on the neglected side of the body.

**Functions compromised when a specific region of the

brain is damaged by stroke can sometimes be taken
over by other parts of the brain. This ability to adapt
and change is known as neuroplasticity.

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Occupational and recreational therapists

Like physical therapists, occupational thera­

pists are concerned with improving motor and
sensory abilities, and ensuring patient safety
in the post-stroke period. They help survivors
relearn skills needed for performing self-
directed activities (also called occupations)
such as personal grooming, preparing meals,
and housecleaning. Therapists can teach
some survivors how to adapt to driving and
provide on-road training. They often teach
people to divide a complex activity into its
component parts, practice each part, and
then perform the whole sequence of actions.
This strategy can improve coordination and
may help people with apraxia relearn how
to carry out planned actions.

Occupational therapists also teach people

how to develop compensatory strategies and
change elements of their environment that
limit activities of daily living. For example,
people with the use of only one hand can
substitute hook and loop fasteners (such as
Velcro) for buttons on clothing. Occupational
therapists also help people make changes
in their homes to increase safety, remove
barriers, and assist physical functioning,
such as installing grab bars in bathrooms.

Recreational therapists help people with a

variety of disabilities to develop and use
their leisure time to enhance their health,
independence, and quality of life.

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Speech-language pathologists

Speech-language pathologists help stroke

survivors with aphasia relearn how to use
language or develop alternative means
of communication. They also help people
improve their ability to swallow, and they
work with patients to develop problem-solving
and social skills needed to cope with the
after-effects of a stroke.

Many specialized therapeutic techniques have

been developed to assist people with aphasia.
Some forms of short-term therapy can improve
comprehension rapidly. Intensive exercises
such as repeating the therapist’s words, prac­
ticing following directions, and doing reading
or writing exercises form the cornerstone of
language rehabilitation. Conversational coach­
ing and rehearsal, as well as the development
of prompts or cues to help people remember
specific words, are sometimes beneficial.
Speech-language pathologists also help stroke
survivors develop strategies for circumventing
language disabilities. These strategies can
include the use of symbol boards or sign lan­
guage. Recent advances in computer technology
have spurred the development of new types of
equipment to enhance communication.

Speech-language pathologists use special types

of imaging techniques to study swallowing
patterns of stroke survivors and identify the
exact source of their impairment. Difficulties
with swallowing have many possible causes,
including a delayed swallowing reflex, an
inability to manipulate food with the tongue, or

12
an inability to detect food remaining lodged
in the cheeks after swallowing. When the
cause has been pinpointed, speech-language
pathologists work with the individual to devise
strategies to overcome or minimize the deficit.
Sometimes, simply changing body position and
improving posture during eating can bring
about improvement. The texture of foods can
be modified to make swallowing easier; for
example, thin liquids, which often cause chok­
ing, can be thickened. Changing eating habits
by taking small bites and chewing slowly can
also help alleviate dysphagia.

Vocational therapists

Approximately one-fourth of all strokes occur

in people between the ages of 45 and 65. For
most people in this age group, returning to
work is a major concern. Vocational therapists
perform many of the same functions that
ordinary career counselors do. They can help
people with residual disabilities identify
vocational strengths and develop résumés
that highlight those strengths. They also can
help identify potential employers, assist in
specific job searches, and provide referrals
to stroke vocational rehabilitation agencies.

Most important, vocational therapists educate

disabled individuals about their rights and
protections as defined by the Americans with
Disabilities Act of 1990. This law requires
employers to make “reasonable accommoda­
tions” for disabled employees. Vocational
therapists frequently act as mediators between
employers and employees to negotiate the
provision of reasonable accommodations in
the workplace.

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When can a stroke patient
begin rehabilitation?

R
ehabilitation should begin as soon as a
stroke patient is stable, sometimes within
24 to 48 hours after a stroke. This first stage of
rehabilitation can occur within an acute-care
hospital; however, it is very dependent on the
unique circumstances of the individual patient.

Recently, in the largest stroke rehabilitation

study in the United States, researchers com­
pared two common techniques to help stroke
patients improve their walking. Both meth­
ods—training on a body-weight supported
treadmill or working on strength and balance
exercises at home with a physical therapist—
resulted in equal improvements in the indi­
vidual’s ability to walk by the end of one year.
Researchers found that functional improve­
ments could be seen as late as one year after
the stroke, which goes against the conven­
tional wisdom that most recovery is complete
by 6 months. The trial showed that 52 percent
of the participants made significant improve­
ments in walking, everyday function, and
quality of life, regardless of how severe their
impairment was, or whether they started the
training at 2 or 6 months after the stroke.

Where can a stroke patient

get rehabilitation?

A
t the time of discharge from the hospital,
the stroke patient and family coordinate
with hospital social workers to locate a suitable
living arrangement. Many stroke survivors
return home, but some move into some type
of medical facility.

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Inpatient rehabilitation units

Inpatient facilities may be freestanding or

part of larger hospital complexes. Patients
stay in the facility, usually for 2 to 3 weeks,
and engage in a coordinated, intensive pro­
gram of rehabilitation. Such programs often
involve at least 3 hours of active therapy a day,
5 or 6 days a week. Inpatient facilities offer
a comprehensive range of medical services,
including full-time physician supervision and
access to the full range of therapists special­
izing in post-stroke rehabilitation.

Outpatient units

Outpatient facilities are often part of a

larger hospital complex and provide access
to physicians and the full range of therapists
specializing in stroke rehabilitation. Patients
typically spend several hours, often 3 days
each week, at the facility taking part in coor­
dinated therapy sessions and return home at
night. Comprehensive outpatient facilities
frequently offer treatment programs as
intense as those of inpatient facilities, but
they also can offer less demanding regimens,
depending on the patient’s physical capacity.

Nursing facilities

Rehabilitative services available at nursing

facilities are more variable than are those at
inpatient and outpatient units. Skilled nurs­
ing facilities usually place a greater emphasis
on rehabilitation, whereas traditional nursing
homes emphasize residential care. In addition,
fewer hours of therapy are offered compared to
outpatient and inpatient rehabilitation units.

15
Home-based rehabilitation programs

Home rehabilitation allows for great flexibility

so that patients can tailor their program of
rehabilitation and follow individual schedules.
Stroke survivors may participate in an inten­
sive level of therapy several hours per week
or follow a less demanding regimen. These
arrangements are often best suited for people
who require treatment by only one type of
rehabilitation therapist. Patients dependent
on Medicare coverage for their rehabilitation
must meet Medicare’s “homebound” require­
ments to qualify for such services; at this time
lack of transportation is not a valid reason
for home therapy. The major disadvantage
of home-based rehabilitation programs is
the lack of specialized equipment. However,
undergoing treatment at home gives people
the advantage of practicing skills and devel­
oping compensatory strategies in the context
of their own living environment. In the recent
stroke rehabilitation trial, intensive balance
and strength rehabilitation in the home was
equivalent to treadmill training at a rehabili­
tation facility in improving walking.

What research is being done?

T he National Institute of Neurological Dis­

orders and Stroke (NINDS), a component
of the U.S. National Institutes of Health (NIH),
has primary responsibility for sponsoring
research on disorders of the brain and nervous
system, including the acute phase of stroke and
the restoration of function after stroke. The
NIH’s Eunice Kennedy Shriver National Institute
of Child Health and Human Development

16
(NICHD), through its National Center for
Medical Rehabilitation Research, funds work
on mechanisms of restoration and repair
after stroke, as well as development of new
approaches to rehabilitation and evaluation
of outcomes. Most of the NIH-funded work
on diagnosis and treatment of dysphagia is
through the National Institute on Deafness
and Other Communication Disorders. The
National Institute of Biomedical Imaging and
Bioengineering collaborates with NINDS and
NICHD in developing new instrumentation
for stroke treatment and rehabilitation. The
National Eye Institute funds work directed
at restoration of vision and rehabilitation for
individuals with impaired or low vision that
may be due to vascular disease or stroke.

The NINDS supports research on ways to

enhance repair and regeneration of the
central nervous system. Scientists funded
by the NINDS are studying how the brain
responds to experience or adapts to injury
by reorganizing its functions (plasticity)—
using noninvasive imaging technologies to
map patterns of biological activity inside
the brain. Other NINDS-sponsored scientists
are looking at brain reorganization after
stroke and determining whether specific
rehabilitative techniques, such as constraint-
induced movement therapy and transcranial
magnetic stimulation, can stimulate brain
plasticity, thereby improving motor function
and decreasing disability. Other scientists
are experimenting with implantation of
neural stem cells, to see if these cells may
be able to replace the cells that died as a
result of a stroke.

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Where can I get more information?

F or more information on neurological dis­

orders or research programs funded by the
National Institute of Neurological Disorders and
Stroke, contact the Institute’s Brain Resources
and Information Network (BRAIN) at:

BRAIN
P.O. Box 5801
Bethesda, MD 20824
800-352-9424
www.ninds.nih.gov

Information about stroke and rehabilitation also

is available from the following organizations:

American Stroke Association:

A Division of American Heart Association

7272 Greenville Avenue

Dallas, TX 75231-4596
888-478-7653
www.strokeassociation.org

Easter Seals
233 South Wacker Drive, Suite 2400
Chicago, IL 60606
312-726-6200
800-221-6827
www.easterseals.com

National Rehabilitation Information Center

8201 Corporate Drive, Suite 600
Landover, MD 20785
301-459-5900
800-346-2742
www.naric.com

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Eunice Kennedy Shriver National Institute

of Child Health and Human Development
National Institutes of Health/DHHS
Information Resource Center
P.O. Box 3006
Rockville, MD 20847
800-370-2943
www.nichd.nih.gov

National Stroke Association

9707 E. Easter Lane, Building B
Centennial, CO 80112
303-649-9299
800-787-6537
www.stroke.org

Information about aphasia also is available

from the following organizations:

American Speech-Language-Hearing
Association
2220 Research Boulevard
Rockville, MD 20852-3289
301-296-5700
800-638-8255
www.asha.org

Aphasia Hope Foundation

2436 West 137th Street
Leawood, KS 66224
913-402-8306
www.aphasiahope.org

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National Aphasia Association

350 Seventh Avenue, Suite 902
New York, NY 10001
212-267-2814
800-922-4622
www.aphasia.org

National Institute on Deafness and

Other Communication Disorders
National Institutes of Health/DHHS
Information Clearinghouse
1 Communication Avenue
Bethesda, MD 20892-3456
800-241-1044
www.nidcd.nih.gov

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Prepared by:
Office of Communications and Public Liaison
National Institute of Neurological
Disorders and Stroke
National Institutes of Health
Department of Health and Human Services
Bethesda, Maryland 20892 -2540

NIH Publication No. 14 -1846 September 2014