You may be familiar with the common signs and symptoms of a stroke: loss of vision, drooping face, weak limbs, and slurred speech. But what happens during the recovery phase, once a patient has spent time in the hospital and their brain has begun to recover?

Lester Leung, a vascular neurologist at Tufts Medical Center and associate professor at Tufts University School of Medicine, Gabriele Moriello, a physical therapist and associate professor in the Department of Rehabilitation Sciences at the School of Medicine, and David Thaler, a vascular neurologist at Tufts Medical Center and professor at the School of Medicine, recently shared how stroke patients recover and what factors may help or hinder the process.

The Shape of Recovery

There are two main categories of strokes: ischemic strokes and hemorrhagic strokes. Most strokes, about 87%, are ischemic strokes, caused by the blockage of a blood vessel in the brain. Hemorrhagic strokes, about 13% of strokes, are caused by bleeding in the brain.

Both types of strokes can damage healthy brain tissue. But the two types have slightly different trajectories of recovery. A patient with an ischemic stroke will see their brain function and mobility drop down after a stroke, then begin to improve starting as soon as 24 hours after their stroke.

A person with a hemorrhagic stroke also loses brain function quickly after a stroke. But because there is blood in the brain, hindering its function, it takes longer for that person’s function to return. As blood reabsorbs into the brain, “there’s a very steep potential incline in terms of regaining function, but it’s delayed,” Leung said.

For both ischemic and hemorrhagic strokes, the potential for improvement is high, Thaler said. The “shape” of recovery is also similar: People improve quickly early on, then their progress begins to slow. And while the severity of a stroke doesn’t typically change the shape of recovery, it does affect the extent to which a person will ultimately improve, he said—a person with a mild stroke may regain all their functions, while someone with a severe stroke, such as one that paralyzed them, may not ever recover completely.

“Recovery is different for every single person,” Moriello said.

Rebuilding the Brain

As soon as 24 to 48 hours after a stroke, physical therapists like Moriello will begin to mobilize a stroke patient, asking them to get out of bed, stand up, and walk around. A person’s long-term outcomes are better the sooner they’re able to get up and moving, she said. 

Next, people who can tolerate three hours of therapy per day typically head to inpatient rehab, which may include physical therapy (a method to improve physical movement and mobility), occupational therapy (similar to physical therapy, but based on the movements a person needs to carry out their role in life), speech therapy (which focuses on speech and swallowing), or a mix of all three. 

After one to three weeks of inpatient rehab, the patient will usually head home, where they’re able to continue therapy via home visits from therapists or by attending an outpatient therapy center. Home care and outpatient therapy usually last three to six months, after which insurance typically stops covering it, Leung said. 

Therapies like these work because the brain is “plastic,” or able to adapt its abilities, Moriello said. Therapies after a stroke use repetition to reinforce or even recreate neural pathways associated with movement that may have been lost or damaged during the stroke. “We have to make sure a patient is getting enough repetition that we’re changing their brain, so that they can get back to doing some of the things they were doing before the stroke,” she said.

“The brain needs to re-learn that these things are important,” Leung said.

A stroke can also affect a patient’s emotional health. About half of stroke patients experience an increase in symptoms of anxiety and depression, and some patients also deal with post-traumatic stress disorder. “Strokes are scary, and they make people introspective and concerned about a potential second stroke,” Thaler said. Physicians typically refer patients struggling with anxiety and depression after a stroke to counseling or psychotherapy. In some cases, they also prescribe a patient medications meant to improve mental health.

Leung hopes that physicians who treat stroke patients begin to think of stroke recovery as a never-ending process. There’s a misconception that stroke patients reach their maximum recovery within a few months after their stroke. “That’s the dominant narrative,” Leung said. But research shows that a person can continue to regain function throughout their life. “We have to shift our understanding of stroke,” he said. Leung also hopes that ongoing research will help physicians better personalize therapies for stroke patients based on the location of their stroke in the brain, among other factors.

Moriello and Leung also stressed the importance of counseling patients during recovery about how to avoid a second stroke. The risk factors for a second stroke are very similar to risk factors for a first stroke, with heart disease, diabetes, high blood pressure, and obesity at the top of the list. Losing weight and improving cardiovascular health through diet and exercise can mitigate those risk factors. Counseling for prevention “should be involved in every single person’s stroke recovery,” Moriello said. 

Healing Factors

Many factors can either improve or hinder someone’s recovery. How quickly someone can get medical care, and the type of care they’re able to get, play a large role, Moriello said. People who are able to recognize stroke symptoms quickly and get to a comprehensive stroke center are more likely to recover well. 

Two relatively new stroke treatments also provide a huge benefit to patients: intravenous medications that break up clots in the brain, called tissue plasminogen activator, or tPA, and a procedure called mechanical thrombectomy, in which a surgeon retrieves a clot using a catheter. Both treatments improve patient outcomes significantly, Thaler said, but need to be done within the first few hours of symptoms.

Proximity to a comprehensive stroke center (a hospital with certified abilities to treat stroke cases) largely determines whether someone will be able to get appropriate care. But insurance also matters—research shows that patients with insurance that covers hospital care after a stroke have better outcomes and a lower risk of death.

Thaler pointed out that even without neurological improvement, there are ways to improve a patient’s quality of life, such as teaching the patient how to navigate daily tasks with the abilities they still have. For example, a patient with a completely paralyzed arm might learn how to use their other limbs in new ways to supplement their mobility. Promising new technologies—some that stimulate the brain to amplify its signals—can also improve patients’ lives, though research is ongoing, Leung said. 

A person’s support network can make a huge difference, too. For example, if someone recovering from a stroke has friends and family nearby, those loved ones can help them practice their therapies outside of a medical setting. “That helps us get in all the repetition that we need to make people better,” Moriello said. 

The landscape of stroke recovery and rehabilitation is evolving in a positive direction, allowing survivors to lead meaningful and enjoyable lives, Leung said. Nonetheless, he added, there is a critical need for further research to continue to progress rehabilitation strategies.