This is one of the most asked – and often confusing aspect of stroke recovery. What is happening as time passes ? What should be done at what time ? Which therapy is suitable when ? Does stroke recovery last a lifetime ?
Research was done on this by the first “Stroke Recovery and Rehabilitation Roundtable” in 2017 and a paper published that can be found here. It established a set of common language and definitions which aid in stroke recovery research and consequent therapies. The following image taken from this paper summarizes its findings.
As seen above, the timeline following a stroke is divided into five distinct phases. These phases are based upon what is happening inside the brain of a stroke affected person. These phases are set out as under :
Hyperacute : First 24 hours after the onset of stroke
In this stage, blood supply to the brain is disrupted. Accordingly, oxygen and nutrient supply to brain cells does not happen. Cells not receiving such are dying. A brain cell can survive only for about five minutes after such disruption . Whatever functions that cell / brain area is controlling is impacted upon death of that brain cell / damage to that brain zone.
Hence, this phase is extremely time critical. Stroke symptoms have to be recognized and the affected taken to a stroke ready hospital at the earliest so that appropriate treatment may start earliest. Every second counts !
Acute : 1-7 days from onset of stroke
In this stage an area known as ” penumbra” develops around the completely dead brain tissue. The penumbra has billions of brain cells that may be failing and non-functional at the moment. However, there is a possibility that they may still recover. This is known as diaschisis and serves as the mechanism of what is called spontaneous recovery.
Spontaneous recovery doesn’t depend upon therapy. This is rapid recovery that happens by itself in this phase as well as the next one – the early sub-acute phase.
Treatment in this phase is primarily ‘ bed-side’ therapy that can be tolerated by the affected. The objective is achievement of basic movements as early as possible – such as standing up, rolling, sitting in bed, opening and closing the hand, walking etc. The therapists and even family members guided by the therapist can help. An iterative process takes place, at which time the damage to the brain and corresponding body functions is also being found and assessed by doctors, therapists etc.
” Compensation” should be avoided in this phase. Compensation is using good limbs and possible movements to avoid using the affected limbs. Compensation can develop “bad habits” instead and should be avoided at this stage.
Early Sub-acute : 7 days to 3 months from onset of stroke
In this phase, the patient begins stroke rehabilitation, after being so cleared by the doctors. The ” neuroplasticity” of the brain is being tapped into. Idea is to form new neural connections that may take over the functions of the dead brain cells, as well as encourage revival of the penumbra cells as much as possible.
In this phase stroke recovery can happen but it takes intense work. At the same time, there is a tendency of the affected ( and perhaps encouraged by the therapist/ family members as well ) to go for “compensation” .That does not help the brain cells recover. So compensation should still be avoided.
This is the time to take as much guidance as possible from the therapists and intensively practice the ” right” movements as much as possible . This will encourage the neuroplastic developments needed. ” Use it or lose it” is applicable to brain as well. Again, the goal is to recover and NOT compensate !
Late sub-acute : 3 to 6 months from onset of stroke
Many brain cells/ neurons may have come “online” again because of the natural spontaneous recovery as well as the rehabilitation efforts. While some may have recovered quite well, many may not be the same as before. They may be trying to adapt to the changed situations, trying to develop new pathways around the damaged ones.
This shows up in the patient in many ways- movements become slower, cognitive abilities such as memory are the not the same as “before” . Depression may set in, incontinence may have to be dealt with.
However this does not mean no more recovery is going to happen. Progress may seem in small steps but done consistently over time these small steps add up to huge leaps ! So it is time to become persistent and keep on striving !
Chronic : After six months from onset of stroke, for the lifetime of the stroke affected
Most of the neural “repair” possible has taken place . Various damaged brain cells and pathways are working at different degrees of recovery, which is showing up in the patient. Chances of fast and spontaneous recovery are now lesser. At the same time, the affected patients are increasingly replying on compensatory strategies leading to what is known as ” learned non-use” which in turn is detrimental to recovery. Also, regular visits of an external therapist may have lessened, or stopped altogether . Thus much more discipline and determination from the affected as well as the family caregivers is required to do whatever they can
However recovery is still very much possible ! Neuroplasticity is coming to the fore and increasingly, research suggests that functional improvements can still happen. A therapist, caregivers and the affected can work together to develop a plan and record progress on it. There are now mobile apps as well available that may help.
We hope above is useful to the readers to find out which stage of recovery they or their loved ones are, and work on further treatments accordingly. Thought and comments welcome !
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