Stroke Recovery: Is Full Rehabilitation Possible?

A stroke is a medical emergency that occurs when blood flow to the brain is interrupted. The recovery process after a stroke varies from person to person, with some individuals experiencing a faster recovery within days or weeks, while others may require months or years to recuperate and adapt to lifestyle changes. The severity of the stroke, the speed of initial treatment, and the type and intensity of rehabilitation all influence the likelihood of a full recovery. While there is no guaranteed outcome, early and intensive rehabilitation, motivation, and a positive attitude are key factors in optimising the chances of a full recovery.

Prompt identification and treatment

The acronym FAST can be used to quickly identify stroke symptoms:

• Face: Ask the person to smile and observe if one side of the face droops.
• Arms: Check if both arms can be raised evenly or if one drifts downward.
• Speech: Observe if the person is having trouble speaking or slurring their words.
• Time: Call emergency services if any of these signs are present.

Once a stroke is suspected, it is vital to receive initial treatment as soon as possible. The first 24 hours after a stroke are critical, and the patient is typically admitted to an emergency department to stabilise their condition and determine the type of stroke. If the stroke is caused by a blood clot (ischemic stroke), clot-busting medication can be administered to reduce long-term effects if given promptly.

During the initial days and weeks after a stroke, the focus is on stabilising the patient's condition and starting rehabilitation as soon as possible. The rehabilitation team consists of various specialists, including physiatrists, neurologists, physical and occupational therapists, speech-language pathologists, and nurses. They work together to address the physical, cognitive, and emotional impacts of the stroke. The typical length of a hospital stay after a stroke is five to seven days, during which the team evaluates the patient's condition and develops a personalised rehabilitation plan.

The first three months after a stroke are considered the most crucial period for recovery, as the brain enters a heightened state of neuroplasticity, making it more receptive to adaptation and recovery. Intensive rehabilitation during this time can enhance the chances of a full recovery. However, it is important to note that recovery can continue for months and even years after a stroke, and setbacks may occur. Therefore, persistence, internal motivation, and a positive attitude are essential to enhancing recovery outcomes.

Lower stroke severity

The severity of a stroke is a major factor in determining the likelihood of a full recovery. The faster you receive treatment, the better your chances of recovery. However, the recovery process can be slow and uncertain, and it differs from person to person.

The first three months after a stroke are critical for recovery, with most improvements occurring during this period. The extent of the initial injury is a significant factor in determining the likelihood of a full recovery. Successful thrombolytic therapy can limit the initial injury and result in less severe chronic deficits.

Some factors that can influence the severity of a stroke and the chances of a full recovery include:

• Age: Older age is often associated with poorer outcomes after a stroke, with almost half of older stroke survivors experiencing mild to severe disabilities. However, the impact of age on long-term recovery is less pronounced, and other factors may play a more significant role.
• Gender: Females tend to have more difficulty achieving complete functional independence after a stroke than males. They are also more likely to experience depressive symptoms and fatigue, which can negatively impact recovery.
• Race: In the United States, Blacks have a higher stroke incidence, higher stroke mortality, and greater initial stroke severity than Whites. Racial disparities in access to acute therapy and rehabilitation services may contribute to poorer stroke outcomes in Blacks compared to Whites.
• Socioeconomic status: Individuals with lower socioeconomic status often have higher stroke incidence and poorer short and long-term outcomes. This may be due to limited access to healthcare and rehabilitation services, as well as a higher prevalence of co-morbidities and cerebrovascular risk factors.
• Medical history: Pre-existing health conditions, such as diabetes, uncontrolled diabetes, and severe peri-ventricular white matter disease, can negatively impact stroke recovery.
• Initial injury: The severity of the initial injury is a major determinant of chronic recovery. More severe acute motor impairments are likely to result in more severe chronic deficits.
• Rehabilitation: The type, timing, and dosage of rehabilitation therapy can influence motor recovery. While high-intensity rehabilitation therapy may be beneficial in some cases, it can also impede recovery if administered too early after a stroke.

While these factors can influence the likelihood of a full recovery, it is important to note that recovery is a complex and dynamic process, and each person's experience will be unique.

Early rehabilitation

Johns Hopkins stroke rehabilitation specialist, Preeti Raghavan, M.D., says:

> "Starting rehabilitation as soon as possible after the cause of the stroke is treated is vital in stroke recovery...At Johns Hopkins, rehabilitation starts around 24 hours after a stroke."

Raghavan also notes that the first three months after a stroke are the most important for recovery, and this is when patients will see the most improvement. During this time, most patients will enter and complete an inpatient rehabilitation program or make progress in their outpatient therapy sessions.

The goal of early rehabilitation is to restore function as closely as possible to pre-stroke levels or develop compensation strategies to work around any functional impairments. For example, learning to hold a toothpaste tube so that the strong hand can unscrew the cap.

The rehabilitation team includes physiatrists, neurologists, physical and occupational therapists, speech-language pathologists, and nurses. They meet daily to discuss the patient's condition, and some form of therapy is delivered as often as every hour during the first day or two. Therapy sessions are conducted up to six times a day while the patient is in the hospital, helping to evaluate the damage caused by the stroke and jump-start the recovery process.

The types of therapy provided during early rehabilitation include:

• Physical therapy to help with movement and address issues such as numbness on one side of the body.
• Cognitive behavioural therapy (CBT) to address anxiety, depression, and tiredness.
• Cognitive rehabilitation to improve memory, concentration, thinking, and mood.
• Speech therapy to improve problems with swallowing and vision.
• Bowel or bladder therapy, which includes advice, exercises, and medicines.

Setting achievable goals

After a stroke, the road to recovery can be long and challenging. Setting achievable goals is a great way to stay motivated and focused on your recovery journey. Here are some tips to help you set realistic and meaningful goals:

Identify Your Goals

Start by figuring out what you want to achieve. Consider your priorities and what is important to you. For example, you may want to improve your communication skills, increase your confidence in social situations, or start exercising regularly. Think about both short-term and long-term goals, as recovery is a gradual process.

Make Your Goals Specific and Achievable

While it's great to have broad goals like "being more social" or "improving communication", it's important to make them more specific and achievable. Instead of saying "I want to get back to normal", try something more concrete, such as "I want to weed the garden" or "I want to introduce myself at a stroke group meeting". This will make it easier to measure your progress and stay motivated.

Break Your Goals into Small Steps

Break down your goals into smaller, more manageable steps. For instance, if your goal is to walk a certain distance, start by setting a goal of walking to your mailbox every day. Once you achieve that, you can gradually increase the distance. Taking small steps will help you stay motivated and build towards your ultimate goal.

Work with Your Therapy Team

Your rehabilitation team will likely include physical therapists, occupational therapists, speech therapists, and other professionals. They are a valuable resource for goal setting as they understand your unique challenges and abilities. They can help you set challenging yet realistic goals and incorporate your priorities. They will also be there to support and encourage you as you progress.

Celebrate Your Successes

Recognize and celebrate your achievements, no matter how small they may seem. This is a great way to stay motivated and maintain a positive mindset. Share your successes with your friends and family, and consider joining a stroke support group to connect with other survivors who can relate to your journey.

Remember, recovery from a stroke is a highly individual process, and it's important to be patient and compassionate with yourself. Setting achievable goals will help you stay focused and motivated as you work towards regaining function and independence.

Speech and language therapy

Initial Assessment and Screening

Speech and language therapists are involved in the initial assessment of swallowing and communication difficulties following a stroke, ideally within 24 hours of the acute stages. They also train other healthcare professionals to carry out screening and provide long-term rehabilitation as part of the transdisciplinary team.

Communication Difficulties

One-third of stroke survivors experience communication difficulties, which can include:

• Receptive aphasia: Difficulty understanding what is being said.
• Expressive aphasia: Difficulty using words and sentences to express thoughts.
• Word-finding difficulties: Trouble thinking of the desired words.
• Dyslexia: Reading difficulties.
• Dysgraphia: Writing difficulties.
• Dysarthria: Muscle weakness that affects speech, making it slurred or hard to understand.
• Dyspraxia: Difficulty with the sequential movement of muscles required for clear speech.

Therapists work with stroke survivors to set personal communication goals and employ various approaches, such as intensive therapy, online therapy, and home-based therapy programmes. They also assess and recommend communication aids and assistive technology to minimise the impact of communication difficulties.

Swallowing Difficulties

Up to 78% of stroke survivors initially experience dysphagia (difficulty swallowing), which can lead to malnutrition, dehydration, choking, and aspiration. Speech and language therapists assess and support these individuals to minimise the risk of aspiration and choking. They also provide strategies to help stroke survivors enjoy food and drink safely and enable them to eat out and socialise confidently.

Exercises for Speech Improvement

• Breathing exercises: Regulating breathing while speaking can be challenging for stroke survivors. Planning breaths and practising sentences with appropriate breathing pauses can help.
• Tongue strengthening exercises: Tongue stretches and exercises strengthen the tongue muscle and improve neural pathways, making it easier to form words.
• Practising speech sounds: Focusing on specific sounds and words can help stroke survivors improve their speech clarity and strength.
• Sentence practice: While word formation may be challenging, forming complete and correct sentences is also important. Combining word practice with sentence construction can help link speech to communication.

Frequently asked questions