When should rehabilitation after a stroke begin?

In most cases, rehabilitation begins on the neurology ward, where the first attempts are made to help the patient sit up. If this is not possible because of the deficits caused by the stroke, bedside rehabilitation is often used, which includes measures to prevent pressure sores and blood clots. If the patient is discharged from hospital while still bedbound and comes under the care of their loved ones, it is worth reading about the positioning described in our guide to preventing contractures and pressure sores.

To prevent immobility, rehabilitation — as part of measures to prevent pressure sores and blood clots — is often introduced as early as the neurology ward, under the close care of the doctor in charge. Vital functions are monitored throughout, such as a rise in blood pressure during physical exertion. How many days after admission a patient begins rehabilitation is closely tied to a range of parameters influenced by a great many factors. That is why the doctor, while monitoring vital functions, makes the decision about rehabilitation individually for each patient.

Some patients leave the rehabilitation ward under their own steam, while others sadly remain bedbound and urgently need rehabilitation of the functions they have lost. How long rehabilitation after a stroke takes depends on many factors. A patient’s functional status can change dramatically between admission and discharge — fortunately, in most cases for the better. Once life is no longer in immediate danger, the doctor usually gives the go-ahead to start rehabilitation.

Introducing rehabilitation quickly helps to engage the patient more actively in their further recovery and has a positive effect on their motivation to work on themselves.

One of the fundamental goals of early rehabilitation is to prevent the potential complications that arise from keeping the patient immobile for too long. The most common of these are:

• the development of abnormal movement patterns,
• contractures,
• respiratory problems,
• psychological problems arising from a sense of helplessness and feeling of no longer being of use.

The initial phase of rehabilitation focuses on basic functions. Patients often have trouble swallowing food, reduced respiratory capacity and impaired oral function, so alongside standard neurological rehabilitation it is important to introduce speech and swallowing therapy early. Swallowing problems can lead to malnutrition and weakening of the whole body, which prolongs the rehabilitation process and reduces its quality.

It is very important to change the patient’s position as often as possible, every 2–3 hours. This weakens the process by which abnormal movement patterns form and helps to shape muscle tone. This stage is sometimes neglected, which increases the risk of entrenching paresis of the hand and upper limb.

The initial phase of rehabilitation also focuses on teaching the patient all the basic movements where necessary: sitting up unaided, rolling onto their side, maintaining a seated position, standing up and taking steps. Early mobilisation into an upright position is extremely important, but the decision to begin it always rests with the doctor. Patients who are mobilised upright early usually have fewer problems later on with abnormally increased muscle tone and with contractures.

Principles to follow in the first stage of rehabilitation

• Do not pull on the paralysed limbs, because the muscles in these limbs are very weak and additional stretching can lead to a partial dislocation of the joint.
• If possible, the patient should eat their meals sitting up rather than lying down or in a semi-seated position, as the latter can make swallowing more difficult.
• The patient should not use the hospital bedside pull-up bars, as these disrupt the correct working of the muscles and encourage poor movement habits.
• A paralysed upper limb should not hang passively, because its weight and the force of gravity strain the shoulder joint apparatus, the capsule, ligaments, nerves and muscles.

In the initial phase of rehabilitation the patient may use a pressure-relieving mattress, but once they have learnt to change position, the mattress should be set aside so as not to accustom the patient to staying in one position for too long, and so as not to deepen problems with perception and spatial orientation.

Respiratory rehabilitation is also very important, as a way of preventing bronchitis and pneumonia. In the first stage, the patient’s back should be patted frequently to prevent secretions from building up. Changing position and mobilising the patient upright are further ways of preventing respiratory complications.

After a stroke, it is important to remember that every rehabilitation process runs differently. The brain’s compensatory plasticity sometimes produces spectacular results in the recovery of function, while at other times the process is decidedly slower and more drawn out. It all depends on the location and extent of the brain damage and on the time that passed between the first symptoms and medical intervention.

The first months after a stroke are a crucial period. This is the time when the patient forms the movement patterns by which they will function later in life. This does not mean, however, that there is no chance of improvement afterwards. Systematic rehabilitation improves the patient’s functioning and allows new motor skills to be acquired throughout life. In the first year, though, it is worth doing everything possible to achieve the greatest improvement through intensive rehabilitation. The patient should undergo rehabilitation 5–6 days a week in order to maximise the results of therapy.

Patients also come to our centre several years after their stroke, or after several strokes. This does not mean there is no chance of improvement. Our experience of providing comprehensive stroke rehabilitation shows that even in patients 5 years after a stroke, positive changes in motor function can still occur.