U.S. DEPARTMENT OF HEALTH 

AND HUMAN SERVICES

Public Health Service

National Institutes of Health

Post-Stroke 

Rehabilitation 

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? 

Rehabilitation 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 consensus 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 acutecare 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 rangeof-motion exercises to strengthen their strokeimpaired 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 assistance. Rehabilitation nurses and therapists 

help patients who are able to perform progressively 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 swallowing. 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 experience 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 

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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 thalamus, 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 immobilized 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 

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centers can severely impair verbal communication. 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 conveying 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 sentences, 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 awareness. 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. 

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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, selfloathing, 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? 

Post-stroke rehabilitation involves physicians; 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 

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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 hydrotherapy (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 therapists 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 selfdirected 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, practicing following directions, and doing reading 

or writing exercises form the cornerstone of 

language rehabilitation. Conversational coaching 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 language. 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 

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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? 

Rehabilitation 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? 

At 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 program 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 specializing 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 coordinated 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 nursing 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. 

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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? 

The National Institute of Neurological Disorders 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 

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(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 constraintinduced 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? 

For more information on neurological disorders 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. 11 -1846 April 2011