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Planning for Rehabilitation and Recovery

Two-thirds of individuals with stroke require rehabilitation. Rehabilitation helps stroke survivors relearn skills or teach survivors new ways of performing tasks to adapt to residual disabilities that occur when part of the brain is damaged by a stroke.

Rehabilitation starts in the hospital following a stroke. In most cases, disability following stroke is most severe at the time of arrival, and gradually lessens with time. In some cases, the symptoms and deficits may fluctuate during the first few days before plateauing.

Once your condition has stabilized, our team requests the assistance of our physical therapists, occupational therapists, and speech therapists. These teams perform detailed evaluations to assess your rehabilitation needs. This involves:

  • Asking you questions to assess your pre-stroke abilities and living situation.
  • Performing a function-based evaluation (cognition, strength, sensory function, coordination, mobility, and balance).
  • Coordinating with your physicians and nurses to develop a consensus on expectations for speed and extent of recovery.
  • Setting short term therapy goals.
  • Establishing a plan for rehabilitation services following discharge from the hospital.

Based on your impairments after stroke, the therapy team develops a care plan and provides recommendations for discharge locations. Several factors influence these recommendations, including safety, projected speed of recovery, and ability to participate with rehabilitation therapies. These discharge locations include the following:

  • Home – Sometimes, the therapists or your physicians may determine that you do not need rehabilitation services. Nonetheless, some subtle impairments may emerge later. If this occurs, make sure to speak with the neurologist you see in the clinic.
  • Home with services – You may be safe to go home, but we still want you to have rehabilitation therapies. In this scenario, you may have a visiting nurse come to your home to help you with rehabilitation exercises. Alternatively, you may be prescribed therapy that you will obtain at one of the therapy clinics at Tufts Medical Center or close to home.
  • Acute rehab – If your impairments are significant and you are able to participate in rehabilitation therapies, we may recommend that you go to an acute rehab hospital. These are facilities with doctors, nurses, and therapists that help guide your rehabilitation and recovery. Generally, we recommend specific “neuro rehabilitation” facilities that have neurologists and physiatrists who are experienced with stroke patients. Please ask about these during your discussions with our case managers.
  • Skilled nursing facility (SNF) – Sometimes, aggressive rehabilitation therapies are not always possible (or may not be possible right away). If you have severe impairments resulting from your stroke or preceding your stroke, it may be recommended that you transition from the hospital to a SNF, at least temporarily. The facilities are able to support patients who remain ill and very impaired by their strokes while still providing some therapy services.
  • Long-term acute care (LTAC) facility – In some situations, you may be very ill and severely impaired after the stroke but still have some potential for recovery. LTAC hospitals can provide intensive medical care and support, including ventilation, feeding support (through gastrostomies), and infusion medications. These facilities do not provide much rehabilitation therapy, but they do provide assessments to monitor your recovery and gauge whether or not you may be able to transition to a different type of facility for rehabilitation services.

The goal of rehabilitation is to improve function so that you can become as independent as possible, particularly with activities of daily living such as bathing, eating, dressing, and walking. We will help you choose the facility based on what works best and is most convenient for you and your family.

Late complications of stroke

Besides the specific disabilities resulting from a stroke, many people develop late complications of stroke. These can occur days, weeks, months, or years following the stroke. It is important for you and your family to watch for these: these complications are treatable, but they can cause discomfort or slow down your recovery from stroke.

Physical

Physical effects may impact your recovery in easily recognizable ways, once you know what to look for. Most people recognize that weakness can develop on one side of the body after stroke, and this is usually immediately present after stroke. Other physical effects are less well known. Other common physical effects include:

  • Central pain syndrome – When sensory processing pathways are damaged by stroke, the brain may process sensations abnormally. For example, cold sensations may feel intensely hot or uncomfortable, or light pressure on the skin can trigger electrical or burning sensations. Central pain is often treated with medications specifically designed to treat neuropathic pain.  
  • Dystonia – Some strokes can trigger occasional, involuntary muscle contractions, resulting in abnormal postures or uncomfortable muscle spasms. Dystonia is often treated with injections of botulinum toxin directly into the affected muscles.
  • Fatigue – When the brain is injured by stroke, it requires a large amount of energy to repair the damaged areas. During the recovery phase, you may experience severe tiredness. You may need to sleep many hours more than you are used to. Post-stroke fatigue is often temporary, but if it persists, your doctor may recommend medications or strategies that help promote wakefulness.
  • Foot drop – When stroke causes weakness on one side of the body, the muscles that lift the foot are often affected. It may be difficult to pick up the front part of your foot, causing you to drag your toes along the ground when walking. Foot drop is often addressed with the use of orthotics that help keep the foot and ankle in a locked position. 
  • Seizures – Injury to the brain can result in disruption of normal electrical signals that the brain uses to communicate between neurons and with other parts of the body. Sometimes, this can result in abnormal electrical discharges that trigger abnormal brain activity, also known as seizures. Seizures can produce a wide variety of symptoms including repetitive twitching of muscles, impaired awareness or consciousness, long pauses (also known as behavioral arrests), or stiffening and rhythmic shaking of the limbs (also known as a generalized tonic clonic seizure). Seizures can be prevented with anti-seizure medications and avoidance of common triggers. 
  • Sensory loss or distortion – You may lose the ability to feel touch, pain, or temperature. You may also have difficulty sensing the position of your limbs and torso. Sensory deficits can hinder your ability to move your limbs appropriately or maintain balance. There are many strategies that can help you adapt to sensory loss.
  • Sleep disturbances – After stroke, many people develop difficulty with sleep. Some people have difficulty falling asleep or staying asleep (insomnia) while others develop trouble breathing when sleeping (sleep apnea). Sleep apnea is particularly problematic for stroke survivors because it can worsen hypertension (high blood pressure) and atrial fibrillation (an abnormal heart rhythm increasing risk for stroke) in addition to causing fatigue. If present, your physicians can refer you to a sleep specialist to undergo a sleep test (polysomnography) to determine whether or not you may benefit from therapies for sleep apnea.
  • Spasticity – Weakness from stroke can induce an imbalance between muscle groups. Over time, the imbalance can result in increased tension in the stronger muscle group. This increase in muscle tone can lock the joint in an uncomfortable position, resulting in pain whenever the joint is moved. Spasticity is often treated with periodic injections of botulinum toxin that help to relax the tight muscles.

These physical complications can be addressed by your neurologist. Your neurologist may enlist the help of therapist and other physicians including physiatrists, sleep specialists, and others.

Communication

After a stroke, you may have difficulty forming words or understanding others. This is known as aphasia. Verbal and written communication is incredibly important in everyday life, and we are committed to working with you to maximize your speech and language recovery. Our Speech and Language Pathologists help you recover the ability to communicate effectively with several strategies including:

  • Retraining word retrieval
  • Participating in group therapy to practice conversational skills
  • Holding structured discussions
  • Focusing on improving initiation of conversation and turn-taking
  • Role-playing common communication situations

You may undergo speech therapy at an acute rehab, in the Speech and Language Pathology clinic at Tufts Medical Center or a site closer to home, or at home with a visiting nurse.

Cognitive

Cognition encompasses many functions of the brain related to organizing thoughts, planning actions, storing and retrieving memories, and making decisions. Damage to the brain from stroke may cause problems with cognition, including:

  • Difficulty concentrating
  • Difficulty with solving problems
  • Difficulty with organizing and planning actions
  • Memory loss

At Tufts Medical Center, our Comprehensive Stroke Center offers detailed neuropsychological testing to provide a detailed assessment of your cognitive symptoms and deficits. We also provide cognitive therapy in the Speech and Language Pathology clinic to help maximize recovery and learn adaptive strategies including:

  • Using a memory log to keep track of daily events to help with memory
  • Using an organizer to plan tasks
  • Increasing awareness of deficits in order to help self-monitoring in the hospital and at home

Emotional

Stroke often impairs emotional control in several ways, potentially making the recovery process difficult for you and your loved ones. These include:

  • Depression
  • Anxiety
  • Post-traumatic stress disorder (PTSD)
  • Expressing inappropriate emotions (also known as pseudobulbar affect)
  • Irritability and mood fluctuations
We believe that it is important to address the impact of stroke on both the brain and the mind: mental health is very important for stroke recovery. We offer guidance and treatment for these mood disturbances and referral to our colleagues in psychiatry if needed.

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