The Stroke Recovery Stages

There are six different stages of stroke recovery in this article. As a physiotherapist who has worked on hyperacute stroke wards, stroke units, in the community and with stroke charity LEGS, I want to give you a brief overview of what you should expect at each stage if you are supporting someone that has had a stroke.  I have chosen to start with the event itself because knowing that a stroke is a medical emergency and acting quickly gives better recovery outcomes.

Stroke Recovery Stage 1: Early Recognition Of Symptoms

Early recognition of a stroke can greatly improve stroke outcomes and treatment options. So much so that the NHS has widely advertised the most common symptoms through the FAST campaign (Face, Arm, Speech and Time).

There are other symptoms too that can also indicate a stroke and these too should be taken seriously and you should call 999:

• Sudden weakness down one side of the body
• Sudden blurred vision or blindness either in one eye or both
• Difficulty in finding the correct words and speaking clearly
• Sudden confusion and dizziness or a sudden fall 
• A sudden severe headache

What To Expect?

The ambulance operator will guide you through what to do.

On arrival the ambulance crew will carry out an initial assessment checking their vitals.

If the ambulance crew also suspect stroke they will take them to the closest hospital with a Hyper Acute Stroke Unit for immediate assessment if at all possible.

Stroke Recovery Stage 2: Admission To Hospital & Hyper-Acute Stroke Unit

Within the the first four hours there will be tests and investigations to rule out other potential diagnoses, and to determine whether they have had a TIA (transient ischemic attack) or a stroke. 

Next they will confirm whether the stroke is heamorragic or ischemic with CT scans.  The immediate treatment will differ depending to the type of stroke.  They are likely to also do an MRI scan to determine the age of the stroke if unknown.

They will aim to transfer the patient to the Hyperacute Stroke Unit (HASU) within four hours and many of these investigations and treatments will be performed from there.

What To Expect

To be asked lots of questions! The medical team will need a full medical history and to know exactly what happened and when and also build a picture of the person before this advent.

There will be many different healthcare workers coming to assess and give treatment and they will taken to go for imaging.

The person who had the stroke will present in many different ways depending on the area of the brain that has been damaged.  The person is likely to be drowsy, frightened and confused.

They will be nil by mouth until they have passed a bedside swallow assessment, normally completed in the first four hours. This is important as if their swallow has been affected it could lead to fluid and food particles going to to the lungs, causing either choking or chest infections over time.

They will be assessed by a physiotherapist and occupational therapist who will start to work on their rehabilitation as soon as they are medically stable to do so. 

They will help them to get out of bed if possible and arrange specialist seating if required.  Early mobilisation i.e. getting out of bed and moving as soon as possible is also linked with better outcomes and the reduction of secondary complications such as chest infections.  

Initial goals of therapy will be decided in conjunction with the patient and / or their next of kin wherever possible. It is important to think about what the person’s likes and dislikes are, their work, hobbies and social life and what will motivate them in therapy to achieve the best results they can.

The person may seem completely different to you. They may be floppy down one side of their body, disorientated, confused, uncoordinated, having difficulty communicating and emotional.  Try to reassure them as much as you can and talk with the medical team.

You will been seen by a stroke recovery coordinator who is likely to be working with the Stroke Association while you are in hospital, they can be a great support throughout the stroke recovery stages.

It is worth pointing out that if your loved one has had a small stroke or their symptoms have resolved, then they will be looking to discharge home from the hyperacute stroke unit and bring them back in for follow up at the stroke clinic.  This can often be a shock for people but it’s a good thing providing the necessary support is in place!

Patients who are fit for discharge and the therapists feel that their rehabilitation needs can be met at home will be picked up by the Stroke Early Supported Discharge team (SESD).  The SESD team consists of physicians, therapists, nurses, dietician  and some have their own carers.  SESD gives rehabilitation therapy at home, with the same intensity and expertise that they would receive in hospital.

In theory but not always in practice the person will move from HASU to a stroke unit within 72 hours providing they are stable enough to do so, however it will depend on the availability of beds at your local stroke unit.

Your local stroke unit is determined by the location of your loved one’s registered GP.  If they are medically unstable then they will need to stay on HASU or even move to intensive care in some cases.

If a loved one has had a stroke and you’re looking for inspiration on what you can get them, read our article on gifts for stroke survivors. I’ve also used my experience working on wards to write this on the hospital gifts that people actually want to receive.

Stroke Recovery Stage 3: Stroke Unit And Early Supported Discharge Team After Stroke

When the local Stroke unit is in the same hospital as the HASU, it’s just a case of transferring to a different ward. If they need to go to a different hospital then which one they go to will depend on their GP.  Here, depending on their presentation, they will receive therapy from physiotherapists, occupational therapists and speech and language therapists (SALT).  

A physiotherapist will work on regain and maintaining movement, build strength and exercise tolerance, improving coordination and balance (sitting and standing) and gait re-education.

An occupational therapist will be looking at cognitive function such as memory, understanding and planning as well as the ability to do every day tasks such as getting dressed, washing and feeding themselves. 

The SALT will be working on the different aspects of communication and speech as well as swallow assessments and adaptive diets.  

Most patients will be seen daily by one if not two of these therapists. They will be working towards the patients rehabilitation goals, monitoring progress, feeding back in multidisciplinary team meetings and helping to planning discharges along with the rest of the team and discharge coordinator. 

Goals will be reviewed weekly and new ones made as needed. Normally but not always the patient will have a key worker who will take the lead on liaising with the family and planning discharge.

What To Expect

You may be asked to join therapy sessions to provide encouragement.

Regular updates and a family meeting when the time comes to plan discharge.

Things may not change as quickly as either you or the person expected, stroke recovery can take a long time and some people will never fully recover.

You might notice more subtle changes in the person for instance their personality may have changed, new behaviours or they may laugh or cry more.  Share these with your key worker.

You may notice that where their arm or leg was floppy it now isn’t and even is becoming tight. This is know as an increase in tone and spasticity, talk to your physiotherapist and they will be able to explain it to you and how best to manage it.

Discharge destinations from here can vary. Most will return home with support, some may go onto further inpatient (mean they stay on site) rehabilitation and some may need to go somewhere they can be cared for in the long term such as a nursing home.

Things might be harder than expected when you first get home as hospitals are very supportive, accessible and adapted environments.  Smalls things even like walking on carpets rather than lino floors, thresholds in doorways and less space make a difference.

It will take time for them and you to adjust being back at home and a new normal. It is not uncommon to feel low at this point.

Things To Help Adjusting To Being Back Home After A Stroke

Having the right equipment in place.

Having a family meeting with the multidisciplinary team on the stroke unit prior to them leaving so that you fully understand the person’s needs and potential risks.

Try to get some rest in before they return home even if it means visiting them less.

Letting friends and family know in advance and asking them to visit and help where they can. It can be overwhelming and tiring thought so arrange not to have everyone turning up in the first few days and spread it out.

Delegate jobs to different people i.e. shopping, help with washing, servicing the car and other admin tasks they can do for you.

Don’t miss your own medical appointments if you have them.

Make a diary or calendar of all appointments and home visits as it can be hard to coordinate carers with therapy visits and district nurses etc. At first you may feel like you just want everyone out of your home but give it some time before you cut down on help and let things get into a routine.

Reach out to organisations that can offer help and support such as the Stroke Association and local stroke groups – let them know you are there and find out what’s on offer even if you don’t attend anything for a while until things settle down.

The SESD team will be looking to discharge patients usually between two and six weeks and pass on to the community teams (this will vary depending on what the ongoing needs of that person are).

You may want to look at private physiotherapy options to supplement you rehabilitation.

Charity LEGS provides in-person group exercise and virtual classes that can be accessed from home for a variety of different levels.  The classes are run by physiotherapists and are good value at approx £5 a class. They also offer social and educational contact too through their neuro cafe every week online. A great way to keep motivated and meet other stroke survivors and their families.

Once your loved one is back home, you might want to consider different activities for them. We’ve written all about it in our ‘activities for stroke patients at home‘ article – hope you find it useful.

Stroke Recovery Stage 4: Inpatient Rehabilitation

Not everyone will need to go to inpatient rehabilitation and therefore experience this stage.  Patients that are referred to inpatient rehabilitation are those who are identified to have ongoing rehabilitation needs that can not be met effectively or sadly in their home environment.

Which rehabilitation setting they go to will depend on their GP, where they live and where beds become available.  The length of stay at the rehabilitation centre will be determined by progress but is often around six weeks and this will be reviewed regularly. 

Discharge planning will start early on in their stay to ensure that the relevant services are aware of them.

What To Expect

Less medical setting more homely, patients will be encouraged to wear their own clothes etc.

Facillities to optimise rehabilitation such as therapy gyms, therapy kitchens, adaptive bathrooms.

Wide variety of different aids and therapy equipment to aid recovery.

Daily therapy from physios, OTs, SALT.

Patients encouraged to take responsibility for the rehab and be motivated to work towards their goals.

Family and friends will be involved as long as the patient agrees.

Ongoing support and referral to community teams will be provided after discharge e.g carers, therapists, stroke nurse etc.

Stroke Recovery Stage 5: Review 

All stroke patients should now receive a six month review and for some patients they will go on to have an annual review. They are usually carried out by a stroke recovery nurse.  This is your opportunity to feed back and raise any concerns you may have and ask for more help if you need it.

What To Expect

The stroke nurse will check progress and attainment of goals.

Look to identify any unmet needs of the stroke survivors and their cares based on what is important to them.

Address these needs through providing educational and emotional support as well as making necessary referrals.

Checks to identify high risk factors such as blood pressure and atrial fibrillation working to ensure optimal secondary prevention.

To gather data to inform future care.

It helps to be prepared for this review with a list of questions or concerns you might have and also to book it for a time of day that won’t be a rush for you and you won’t be disturbed.

They will cover the clinical aspects of care as well as the social and community aspects of care.

Stroke Recovery Stage 6: Life After Stroke

Rehabilitation doesn’t just stop after six months and people can still make meaningful gains for years to come. Keeping up activities, physical exercises and social interaction are all important aspects in maintaining a quality of life.

What To Expect

There will be good days and bad days and progress may slow.

They may be referred to specialist clinics to treat their increase tone and spasticity and be given botox injections and splints to help prevent secondary contractures.

You will hopefully be feeling more confident at home and be in a routine.

This can be a good time to engage in new activities and reignite interests that there may not have been time for before.

To find out how the Stroke Association supports people who have had a stroke watch this video.

Summary Of The Stages Of Stroke Recovery

So there you have it, the stages of stroke recovery as I see it. Everyone’s recovery is different and over different time frames, each with their own hurdles. But rest assured that there are gains to be made and someone to support you though each stage.