When a family member has just had a stroke or is about to leave hospital, the question families ask most is: "How long until they recover?" There is no standard answer. Recovery after a stroke is not a straight line. It is a journey in phases. Because the site and severity of the lesion and the patient's earlier health differ from person to person, the speed of recovery can differ a great deal. Instead of asking how many months until things are better, it helps more to understand first which phases the process has, about how long each phase lasts, and what happens during it.
This article follows the internationally accepted phases of recovery. It goes from the acute phase in hospital, through the golden window after discharge, to the chronic phase of long-term maintenance, and explains the changes in the patient's body, the focus of physiotherapy and how family members can help in each phase. It gives time ranges and not a single number, because natural recovery is fastest in the first few weeks and peaks in the first 3 months. After that the pace slows, but it does not stop.
Overview of the five phases of stroke recovery
The international Stroke Recovery and Rehabilitation Roundtable (SRRR; Bernhardt et al. 2017) set out an accepted timeline of phases for recovery after stroke, so that research and clinical treatment share a common standard. The five phases below can serve as a map for understanding the whole recovery process. Note, however, that this set of phases is a basic framework and a reference course for research, and is not a fixed timetable that applies to every patient:
Hyperacute and acute phases (first 24 hours to first 7 days)
In the first few days after a stroke, the medical focus is on saving life and stabilising the condition. This includes dealing with the brain injury, controlling the condition, and preventing another stroke or complications. Once vital signs are stable, the medical team assesses the patient's mobility and recovery potential, and where it is safe encourages the patient to get out of bed early. Research indicates that receiving rehabilitation in a well-organised multidisciplinary stroke unit in itself helps to improve outcomes (Langhorne, Bernhardt & Kwakkel 2011). The AHA/ASA guideline also recommends that stroke patients be treated in an organised, multidisciplinary inpatient rehabilitation setting (Winstein, Stein et al. 2016).
The patient's physical state
- Vital signs such as blood pressure and heart rate and the state of the nervous system are not yet fully stable and need close monitoring.
- The affected arm and leg may be weak (flaccid), and swallowing difficulty or cognitive problems may also occur at the same time.
- The patient spends much time in bed, so pressure injury, pneumonia and deep vein thrombosis need special prevention.
Rehabilitation priorities in this phase, and how family members can help
- Work with the medical team to get the patient out of bed early and gently, and keep correct positioning in bed.
- Move the patient's joints to keep them flexible, and turn the patient regularly to change position and prevent pressure injury.
- Pay attention to swallowing safety, and feed the patient and clean the mouth as instructed by healthcare staff.
Note that early does not mean the earlier the harder. Early activity should follow the principle of short, frequent and gentle sessions, with the therapist assessing the suitable intensity and building up step by step. Overdoing exercise can have the opposite effect (the scientific basis is explained in the article on stroke rehabilitation theory, in its analysis of the AVERT study).
Subacute phase (first 3–6 months)
When the condition is stable and the patient moves into the rehabilitation stage, the patient enters the most critical golden window of the whole recovery process. One reason this period matters so much is that natural recovery of the body is fastest during it. Kwakkel, Kollen and Twisk (2006) followed 101 patients with a first stroke and found that time alone (that is, natural recovery) explained 16% to 42% of the functional improvement in the first 6 to 10 weeks, and that most of the progress was concentrated in the first 10 weeks or so. In other words, the body has a natural drive to repair itself at this time, and if targeted training is added the effect is naturally doubled.
Understanding when the golden period really peaks. The peak of the recovery golden period is not the first day after the stroke, but roughly 2–3 months after the stroke (the subacute phase). Research shows that targeted training at this stage works best, which also fits the idea of a sensitive period in neuroscience. The most important thing about training is to plan early and go step by step, with the therapist adjusting the intensity of training, and not to rush blindly.
As to which exercises to do each day within the golden period and how to arrange home training, there is a lot of content, so this article first concentrates on clarifying the recovery timeline and the priorities of each phase.
Bridging to home rehabilitation during the transition after discharge
For many families, dischargeis the most uncertain moment. The intensive treatment in hospital comes to an end, but the patient is just in the golden window of recovery. Research has confirmed that rehabilitation training does not need to stop, and should not stop, because of discharge. In the early supported discharge (ESD) model, a multidisciplinary team continues rehabilitation at the patient's home, and its effect is supported by evidence:
In reality, the matter of training dose has to be considered. Rehabilitation training at Hong Kong public day hospitals is generally only about 1–2 times a week, which may not be enough for a patient in the golden window. Home practice together with home physiotherapy is therefore a practical way to make up the amount of training and use the golden window during this period.
Note who the evidence applies to: the research evidence for early supported discharge (ESD) mainly concerns patients with a "moderate" stroke who go home. Most of the patients recruited in the relevant clinical trials had a moderate condition and were suitable to return home. This means that not everyone (especially people with a severe stroke or who cannot go home) can get the same effect. Actual discharge arrangements should be assessed by the medical team according to the individual patient.
Physiotherapy priorities in each phase (overview)
Physiotherapy after stroke is not a fixed programme. It has to keep changing with the phase of recovery and the patient's ability. In general, leg training mainly targets standing, balance and walking (and sit-to-stand training is a key step in regaining the ability to stand and walk), while arm training concentrates on improving arm and hand function. Therapies with research support include gait and fitness training and high-intensity, repetitive task training, and for the arm, constraint-induced movement therapy and robot-assisted training (Langhorne, Bernhardt & Kwakkel 2011).
- Severe: positioning, passive movement, assisted sitting up and weight bearing to start
- Moderate: standing, weight shifting and early walking training
- Mild: refining the gait, balance and endurance, returning to everyday walking
- Severe: keep joint range of movement, prevent contracture, trigger first movements
- Moderate: isolated movements, grasp and coordination, moving towards functional use
- Stress high repetition and task-oriented practice, built into daily activities
Specific programmes for leg training by severity, and for the arm, are chosen according to the patient's current ability, and a physiotherapist assesses which level suits.
Chronic phase (after 6 months)
There is a common misunderstanding that a stroke is fixed after 6 months. It is true that natural recovery of the body slows clearly after the first few months (Kwakkel et al. 2006), but slowing does not mean stopping. A study by Ballester and colleagues (2019) of 219 patients (114 of whom were in the chronic or late chronic stage) found that rehabilitation training improved arm function at every stage, and that patients' response to treatment could continue to more than one year after the stroke. This directly overturns the traditional view that there is no more progress after 6 to 12 months.
The mindset for the chronic phase: progress slows but does not stop. In the chronic phase the speed of recovery slows down, but the chance of progress does not fall to zero. With enough practice, kept up consistently, real functional improvement is still possible in the chronic phase. The focus of this phase is to maintain fitness over the long term, prevent decline, and apply the ability already regained in daily life.
How family members can help in each phase
Family members are not onlookers in the recovery process. They are important partners who cannot be left out. As the phase of recovery changes, the family's role changes too:
In each phase, family members can refer to the points below to set the direction of care:
- First understand which phase of recovery the patient is in, and then adjust expectations and training intensity to the phase.
- Use the golden period of the subacute phase, plan training early and keep up enough practice.
- After discharge, arrange home practice and home physiotherapy to make up for the limited number of day hospital sessions in the public system.
- Have the therapist assess the suitable intensity of training and increase difficulty step by step. Do not overdo exercise early after onset.
- Do not give up easily after 6 months. Continuing training in the chronic phase can still bring progress.