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About two-thirds of people who have had a stroke will need some form of rehabilitation therapy (see "Choosing a rehabilitation program"). For many people, a rehabilitation program can make the crucial difference between regaining the ability to function in daily life or remaining dependent and severely impaired. Others may be too severely impaired to take advantage of rehabilitation.

Choosing a rehabilitation program

You need to weigh a number of important factors when choosing a rehabilitation program. Guidelines published by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services suggest that you ask the following questions:

• If you are considering an outpatient program, is there someone at home who can provide care when you are at home? Is transportation available?
• Does the program provide the services you need, such as speech, physical, or occupational therapy?
• Does the program match your abilities, or is it too demanding or too easy?
• Does the program have a good reputation in the community?
• Is the program certified by the Commission on Accreditation of Rehabilitation Facilities or the Joint Commission on Accreditation of Healthcare Organizations?
• Does the staff include registered physical and occupational therapists and physiatrists?
• If the program is residential, can relatives and friends visit easily?
• Are patients and relatives actively involved in rehabilitation decisions?
• Are relatives encouraged to participate in some rehabilitation sessions and practice with the patient?

What portion of the cost is covered by Medicare or private medical insurance?

Rehabilitation is treatment designed to help you regain some or all of the abilities that were impaired by the stroke. It can entail building strength in your arms and legs, learning how to walk again, improving your speech, and bringing back your memory. Rehabilitation can also teach you how to adapt to a permanent disability — for example, learning to use a wheelchair or getting in and out of the shower by grabbing special bars.

You may think of rehabilitation as something that comes after stroke treatment, but it's actually part of stroke treatment. Health professionals regard it as the final phase of therapy. Rehabilitation is work. Whether it involves physical exercises or speech therapy, improvement will require an investment of time and energy. Additionally, it's not uncommon for someone who has had a stroke to experience depression, which can dampen motivation for the rehabilitation program. If you feel depressed, it's important to seek treatment early so you can proceed with the work of regaining some of your lost functioning. Psychological therapy can help you deal with depression and help you improve social skills that may have been affected by the stroke.

Other aspects of rehabilitation include support groups and education for families on how to care for a relative who is recovering from a stroke. Learning to use a variety of physical and psychological skills can help someone affected by stroke continue to live a rewarding and active life.

Assessing your needs

Rehabilitation begins in the hospital with an assessment of your needs and some basic therapy. The assessment is a survey of your impairments. Are you able to swallow? How is your speech? How is your understanding of language? Have you lost strength in an arm or leg? Has the stroke affected your memory? This assessment will determine what kind of rehabilitation is best for you and where you should go for it.

The type of health care professional who does the assessment varies from hospital to hospital. It may be a physician specializing in rehabilitation, a neurologist, a physical therapist, or a social worker who does case management. People with mild deficits can leave the hospital and get some short-term physical or occupational therapy at home or at an outpatient clinic if they need it. People who have trouble walking or sitting by themselves typically need more intensive therapy at a rehabilitation hospital or a skilled nursing facility. Speech and language therapy can be given either at a rehabilitation facility or at home, depending on the type and degree of impairment and the other deficits the patient has.

Later, you will be able to take a more active role in these exercises with some help, encouragement, and reassurance from the therapist.

Rehabilitation is most effective when a multidisciplinary team is on hand to evaluate your needs and deliver and coordinate your care (see "Rehabilitation specialists"). In reality, however, the recommendation you get rests to a large degree on the personal judgment of the health professional in charge at the hospital. It's to your advantage to have a family member or friend learn about all of the types of rehabilitation therapy and the particular stroke deficits that each one can help. It's also worthwhile to research local facilities to find out what stroke rehabilitation services they offer. With a full range of knowledge, you (or whoever is advocating for you) will be in a strong position to evaluate the hospital's recommendation and decide whether it seems right. If it doesn't, you or your advocate should say why and see whether the hospital can revise its assessment.

Rehabilitation facilities and services

Stroke rehabilitation takes place in the following settings. Although there is some overlap, they differ in the amount and type of therapy given.

Rehabilitation hospitals. These include free-standing hospitals and special units in acute-care hospitals that offer short-term inpatient rehabilitation. The rehabilitation usually lasts about three or four weeks, but it can be slightly more or less depending on your needs. Rehab hospitals provide about three hours of stroke rehabilitation a day, a fairly demanding schedule. Physicians specializing in rehabilitation are actively involved in overseeing each person's care. A variety of other rehabilitation specialists — such as physical therapists, occupational therapists, and speech therapists — meet regularly as a team to discuss each person's progress. Rehab hospitals also have psychologists on hand to treat depression.

Skilled nursing facilities. These are nursing homes with rehabilitation capabilities. They offer a combination of short-term and long-term care. In contrast to rehab hospitals, skilled nursing facilities provide only about an hour and a half of rehabilitation services a day and have fewer rehabilitation specialists. A physician is usually employed part-time. A skilled nursing facility may be the best option for an elderly person who does not have the strength or stamina for the more demanding and comprehensive regimen of a rehabilitation hospital.

Outpatient rehabilitation facilities. These centers allow you to live at home but come during the day for rehabilitation, generally at a hospital or other facility. Here, you will work with physicians and therapists who specialize in stroke rehabilitation. You usually spend several hours a day, several days a week, at the facility. Services include physical therapy, occupational therapy, speech therapy, and social or psychological counseling. To attend outpatient rehabilitation, you need to be physically able to travel between the facility and your home. Comprehensive outpatient rehabilitation facilities offer more flexibility than inpatient facilities because the programs can be adjusted to your needs. The regimen can be just as demanding as that offered by a rehab hospital, or it can be scaled back if you don't need or can't handle such a rigorous program.

At-home rehabilitation. A rehabilitation specialist may come to your home for a set number of hours and days on a short-term basis. The specialists are provided by a home health agency. Home rehabilitation can address physical impairments and speech and language difficulties. The intensity of the program can be tailored to your needs. At-home rehabilitation is usually best for people who need one type of rehabilitation therapist (say, a physical therapist or a speech therapist) instead of several therapists, and who can't get to and from an outpatient facility. But to some extent your choice is dictated by your insurance coverage. At-home rehabilitation may not be covered unless you are homebound — physically unable to leave your home. If you are not homebound but simply lack transportation to and from your home, check with your health insurance provider to find out whether you are covered.

Rehabilitation specialists

Several different types of health care professionals are involved in stroke rehabilitation. Knowing who they are and what they do can help you get the most out of your rehabilitation. Many people benefit from more than one type of therapy. Physical therapy, for example, helps the brain compensate for its injury so that you can regain strength and range of motion in your arms and legs. Occupational therapy can then take over and show you how to do specific tasks, such as putting on a shirt or holding a pen.

Physiatrist. This is a physician who specializes in physical medicine and rehabilitation. A physiatrist often supervises a team of nurses and therapists to come up with a rehabilitation plan and helps evaluate whether the plan is working.

Rehabilitation nurse. This type of nurse helps you learn to carry out the activities involved in daily personal care. These include taking your medication on the right schedule, bathing, using the bathroom, and getting yourself in and out of a wheelchair. Rehabilitation nurses can also teach you exercises and other strategies to control incontinence. Rehabilitation nurses educate relatives, friends, and other caregivers about how to take care of someone who has had a stroke.

Physical therapist. This person evaluates and treats disorders relating to movement, balance, and coordination. A physical therapist also designs exercises to help you regain basic physical skills, such as walking and getting around at home. A physical therapist can guide home health aides and relatives who are working with you at home to help you regain lost functions.

Occupational therapist. This type of therapist helps you return to as many activities of daily life as possible. The therapy involves relearning basic activities such as eating, bathing, dressing, and writing, or mastering new ways of accomplishing these tasks.

Speech-language pathologist. This therapist helps you improve your capacity to speak and understand speech. If your stroke has caused a speech or language disorder, you should also have a hearing evaluation to make sure your communication difficulties stem from damage to the language centers of the brain and not from hearing loss. Having a speech disorder doesn't mean that you have trouble with thinking and reasoning. You may be able to think and imagine as clearly as before the stroke but have difficulty expressing your thoughts or understanding what other people say or write.

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.

Source: from Harvard Health Publications, Copyright © 2008 Harvard University. All rights reserved. Harvard Medical School does not endorse products.
Used with permission of StayWell.
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