What To Expect - Rehabilitation: Stroke

Content provided by the Faculty of the Harvard Medical School

What to expect

The specific strategies used in your rehabilitation will depend on the goals of your therapy. If your goal is to strengthen muscles in your arm or hand, a therapist will give you repetitive exercises to work those muscles. If a goal is to regain speech, you may need exercises to strengthen the muscles in the mouth, face, and throat. Group therapy to practice conversational skills with other people who have had a stroke may also help.

When you start rehabilitation, you will probably notice significant progress on a daily basis. By the time a few weeks have passed, you may have advanced from being unable to sit up to being able to walk independently and take care of yourself. The amount of progress you see and how quickly it occurs depend on the severity of your stroke and the part of the brain it affected. If your main problem is moderate muscle weakness, chances are that your recovery will progress more quickly than if you have more severe problems — for example, language deficits that make it hard for you to understand when therapists and other people talk to you.

Rehabilitation is hard work. Even spending many hours each day for several weeks on repetitive exercises may not produce a full recovery. Most people who need a rehabilitation program are left with some lingering weakness or disability. But for many people, significant recovery is possible. If you start rehabilitation unable to walk because of muscle weakness and severe balance problems, there's a good chance that you will gradually be able to walk on your own at least some of the time, use a wheelchair for the rest of the time, and be self-sufficient enough to wash yourself without assistance.

Regaining your physical abilities

Your exercise regimen will depend on your specific type of disability and may include some or all of the following: walking on a treadmill, walking up or down stairs, using hand or leg weights, and repeatedly bending and extending your arms and fingers. If you can't bear weight on your legs, you may practice walking and other exercises while partially supported by a harness or in a swimming pool, where water can support some of your weight (hydrotherapy). The amount of time you spend in physical rehabilitation will depend on your needs and your stamina, but expect it to last at least a few weeks.

A promising experimental technique for people with moderate weakness in one arm is constraint-induced movement therapy, which involves not just exercising the weak arm but also restraining the stronger arm to force the other one to work harder. The good arm is made unable to work — by being placed in a sling or having a mitt placed on the hand — for up to six hours a day for two weeks while the patient does intense exercises with the weak arm. Preliminary research suggests that constraint-induced movement therapy may help the brain rewire itself, and help people to gain more mobility and dexterity. The technique is being evaluated in a large ongoing trial sponsored by the National Institute on Aging, at six rehabilitation centers around the country.

Another promising technique is functional neuromuscular stimulation, which induces muscle contractions with electrical stimulation from electrodes. A small study in Stroke in 2006 found that people who had a stroke more than a year earlier and who still had difficulty walking showed greater improvement in gait if they had functional neuromuscular stimulation along with exercise and other rehabilitation techniques than if they did not have the neuromuscular stimulation.

Occupational therapy can help you learn practical techniques to make dressing, washing, driving, gardening, and other routine activities more manageable. One technique is to break down a complex activity into small parts, then practicing each part in sequence until you can coordinate them. Occupational therapists also teach you ways to compensate for your physical disability — for example, by using Velcro closures instead of buttons on your shirts, or using walkers, wheelchairs, or other devices as needed.

As a rule, you stand a greater chance of regaining gross motor movements, such as grasping a fork or shaking someone's hand, than fine motor movements, such as typing or playing piano. Gross motor movements are easier and require less control from the brain.

Regaining your speech

With speech and language deficits, the greatest progress usually comes in the first few days of therapy. The two most common speech impairments are aphasia and dysarthria.

Aphasia. This is the term for difficulty using words. Some people with aphasia have trouble talking but can easily understand speech. Others talk easily but can't understand what people are saying. Aphasia is a common problem, especially when a stroke has damaged the left side of the brain, where language is processed. Some people with aphasia get better quickly, but even with speech therapy, others continue to have trouble speaking, finding words, reading, writing, or doing math (the same area of the brain that controls language also governs math skills).

If you have aphasia, rehabilitation will involve a variety of speech and language exercises to help you relearn the ability to understand, speak, read, and write to the extent that you are able. These include repeating words that your therapist says, practicing following directions, and practicing reading and writing. You may also participate in group therapy sessions led by a speech-language pathologist to practice talking with other people who are recovering from strokes. These sessions may involve role-playing common social scenarios such as talking on the phone or ordering food in a restaurant. If you have trouble remembering, the therapist will suggest some practical tools, such as the use of a daily organizer or cue cards posted around the house to prompt you to do such things as plan meals or turn off the stove.

Dysarthria. This is a more specific problem: the inability to speak, even when you are able to understand speech and form proper words in your mind. The condition is caused by an injury to the brain centers that control the tongue, palate, and lips. Speech may be slow or slurred, and one side of the face may droop because the facial muscles are paralyzed. Drooling may also occur.

If you have dysarthria, you will be given exercises to help increase strength and endurance in the muscles used for speech. The therapist will also give you practical instruction on how to improve enunciation, such as asking you to speak more slowly and to take deeper breaths before speaking. Many people with dysarthria also have trouble swallowing, a problem called dysphagia. If this is the case, the speech-language pathologist will give you exercises to strengthen your mouth and throat muscles, as well as tips on how to prevent choking, such as taking small amounts of food at a time, eating slowly, and sitting up while eating. You may also need to eat pureed foods at first and gradually introduce more solid foods as you gain muscle strength.

Last updated:	September 05, 2008