Neurorehabilitation after stroke. Functional assessment, rehabilitation goals, motor recovery, prevention of secondary complications, and a multidisciplinary approach
How rehabilitation helps the brain relearn after a stroke, from measuring what was lost and setting goals to the methods of motor recovery, the complications that must be prevented from the first day, and the team that does the work.
- 11 min read
- 5 questions
- Checked 05 Nov 2026
Contents6 sections
At a glance
- After a stroke, undamaged brain can take over lost work (neuroplasticity), but only with practice: many repetitions of real tasks.
- Recovery is fastest in the first weeks to three months, so rehabilitation starts in the stroke unit as soon as the patient is stable.
- Assessment covers every domain: movement, spasticity, balance, arm, daily living, cognition, speech and swallowing.
- Motor recovery runs from flaccid, through spasticity and fixed patterns (synergies), to selective movement; methods are chosen for the stage.
- Many complications are preventable: a painful shoulder, contractures, pressure ulcers, thrombosis, aspiration pneumonia, falls, depression.
- No named school (Bobath, Brunnstrom, PNF) beats the others; task-specific, intensive practice is what works.
- Rehabilitation is the work of a team, with the patient and family in it.
Why rehabilitation works after stroke
A stroke is the sudden loss of blood supply to part of the brain, by a blocked vessel (ischaemic) or a burst one (haemorrhagic). Neurons in the core die within minutes and do not come back. Yet most patients improve, for three reasons:
- Brain that was stunned but not dead around the core (swelling, the penumbra) recovers in the first days and weeks.
- Other areas take over the lost work. This rewiring, neuroplasticity, is driven by use: the brain strengthens the connections that are practised, like a path through grass that becomes clear only if walked often.
- The patient learns new ways to do things (compensation): one-handed dressing, a stick, a wheelchair.
Rehabilitation feeds the second and third. Its rule is simple: practice what you want to get better at, a lot, and as close to the real task as possible. The opposite also holds. A hand that is not used loses its place in the cortex (learned non-use), and the good side takes over everything.
- when most spontaneous recovery has happened
- 3months
- when recovery usually plateaus, though training still helps later
- 6months
- at least, of combined therapies, the UK target in NG236 for those who can take part
- 3hours a day, 5 days a week
The phases follow the illness: the acute stroke unit (first days), the subacute or rehabilitation phase (weeks to months, in a rehabilitation unit or at home with an early supported discharge team), and the chronic phase in the community, with maintenance and periodic review.
Point at a name or a part to light it.
Brain cells killed by a stroke do not come back, but other brain takes over their work, and it does so most readily in the first weeks: in a large stroke-unit study, about 80 per cent of patients had reached their best function in daily activities by 6 weeks and 95 per cent by about 12.5 weeks. That rewiring is driven by use, so practice of real tasks starts early and is intensive; a limb that is not used loses its place in the cortex. Recovery usually levels off by about 6 months, yet training still helps later.
Simplified: the curves sketch the usual time course, shaped to the share of patients who had reached their best function in daily activities by 6 and 12.5 weeks (movement itself recovers a little sooner), not one patient's measurements; the gap between the two curves shows the direction of the effect of practice, not its size; recovery is drawn as one smooth curve, though arm, leg, speech and daily activities each recover at their own pace and may stop at any stage; the window of plasticity has no sharp end; it fades over the first months.
6 sources
- Aleksiev AR. Physical Medicine and Rehabilitation, lecture 6 handnotes. Medical University of Sofia, 2026; and National Institute for Health and Care Excellence. Stroke rehabilitation in adults (NG236), 2023.
- Jørgensen HS, Nakayama H, Raaschou HO, Vive-Larsen J, Støier M, Olsen TS. Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study. Archives of Physical Medicine and Rehabilitation, 1995;76(5):406–412.
- Winstein CJ et al. Guidelines for adult stroke rehabilitation and recovery, a guideline for healthcare professionals from the American Heart Association and American Stroke Association. Stroke, 2016.
- Murphy TH, Corbett D. Plasticity during stroke recovery: from synapse to behaviour. Nature Reviews Neuroscience, 2009;10(12):861–872.
- Kwakkel G, van Peppen R, Wagenaar RC et al. Effects of augmented exercise therapy time after stroke: a meta-analysis. Stroke, 2004;35(11):2529–2539.
- Wolf SL et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke, the EXCITE randomized clinical trial. JAMA, 2006.
Functional assessment
Stroke can take away movement, sensation, speech, swallowing, vision, thinking and mood, so assessment covers each domain. The tools are named in the exam (general method in functional assessment).
| Domain | Tool |
|---|---|
| Stroke severity and outcome | NIHSS (severity, 0 to 42); modified Rankin Scale (disability, 0 to 6) |
| Motor impairment | Fugl-Meyer Assessment; MRC scale of strength; Brunnstrom stages; Chedoke-McMaster Stroke Assessment |
| Spasticity | Modified Ashworth Scale (0 to 4), Tardieu Scale |
| Balance and walking | Berg Balance Scale, timed up and go, 10-metre walk, 6-minute walk test |
| Arm and hand | Action Research Arm Test (ARAT), Box and Block Test |
| Daily living | Barthel index (0 to 100), FIM (18 to 126) |
| Cognition | MoCA, MMSE; screening for neglect |
| Speech and swallowing | aphasia and dysarthria tests; a swallow screen before any oral intake |
| Mood, quality of life | depression screening; EQ-5D |
From this the team judges the rehabilitation potential: what the patient can realistically regain, given the size and site of the stroke, age, other illness, cognition, mood, motivation and support at home. Bad signs are a large stroke, no movement at all in the arm after some weeks, persistent neglect, incontinence and poor sitting balance at two weeks.
Rehabilitation goals
Goals are set with the patient and family, and are specific, measurable and timed. Short-term goals are steps (sit unsupported for five minutes this week; transfer bed to chair with one helper in two weeks). Long-term goals are about life (walk indoors with a stick, dress alone, return home).
The aims behind them:
- restore as much function as possible, and compensate for what will not return;
- independence in daily activities;
- strength, endurance, balance, gait and coordination;
- cognition and communication;
- prevent secondary complications;
- quality of life and return to the community, work and leisure.
Motor recovery
What happens to movement
After the stroke the opposite side is usually limp at first (flaccid). Over days to weeks tone rises: spasticity, a resistance to stretch that grows with the speed of the stretch, because the brain no longer damps the spinal stretch reflexes. Movement returns first as stereotyped patterns, synergies, in which the whole limb moves as one block, and only later as separate, selective movements. Recovery may stop at any stage.
Untreated, spasticity pulls the body into the typical hemiplegic posture (Wernicke-Mann): the arm flexed at elbow, wrist and fingers, adducted and turned in at the shoulder; the leg straight, the foot pointing down and turned in. The patient walks by swinging the stiff leg out in an arc (circumduction).
| Brunnstrom stage | What is seen |
|---|---|
| 1 | flaccid; no voluntary movement |
| 2 | spasticity appears; synergies start, as associated reactions |
| 3 | spasticity is greatest; voluntary movement only in synergies |
| 4 | spasticity falls; some movement out of synergy |
| 5 | more complex movements independent of synergy |
| 6 | spasticity gone; isolated joint movement, near-normal coordination |
The muscle imbalance
The lectures frame spasticity as an imbalance: overactive muscles (the postural, static ones, such as the arm flexors and the calf) and underactive ones (the phasic, dynamic ones, such as wrist and finger extensors, ankle dorsiflexors). The plan treats both sides.
Point at a name or a part to light it.
After a stroke, the brain no longer damps the spinal stretch reflexes, and tone rises most in the postural muscles: the arm's flexors and the calf. Untreated, they win over the weaker phasic muscles that open the hand and lift the foot, and pull the body into this posture. The leg, stiff at the knee and pointing its foot down, is too long to swing through, so the patient swings it out in an arc. Rehabilitation treats both sides of the imbalance: it relaxes and stretches the overactive muscles and strengthens the underactive ones.
Simplified: the full typical pattern is drawn; most patients show only part of it, and recovery may stop at any stage; one muscle stands for each group, drawn as if seen through the skin, and the shoulder's adductors and the calf's inverting muscles are left out; the swing is drawn from the front, out to the side only; in walking the leg also moves forward; the patient is drawn standing unsupported, without the stick or orthosis most use.
3 sources
- Aleksiev AR. Physical Medicine and Rehabilitation, lecture 4 handnotes (Kabat, Bobath, Brunnstrom and Vojta methods; positioning therapy; postural and phasic muscles) and lecture 6 handnotes. Medical University of Sofia, 2026.
- Cifu DX (ed). Braddom’s Physical Medicine and Rehabilitation, 6th edition. Elsevier, 2021. Chapters on stroke syndromes and on spasticity.
- Perry J, Burnfield JM. Gait Analysis: normal and pathological function, 2nd edition. SLACK, 2010. Chapter on hemiplegia and pathological swing.
| Relax the overactive muscles | Strengthen the underactive muscles |
|---|---|
| positioning against the spastic pattern | task-specific and functional exercise |
| slow, sustained stretching; post-isometric relaxation | motor learning with many repetitions |
| cryotherapy (prolonged cold lowers spasticity for a while) or warmth to relax | NMES and FES of the weak muscles |
| resting splints, orthoses | balance and gait training with orthoses |
| botulinum toxin for focal spasticity; oral baclofen or tizanidine when spasticity is widespread | hydrotherapy and exercise in water |
Spasticity is treated only when it harms: pain, contractures, hygiene, posture, or blocked function. Some leg spasticity helps the patient stand.
The methods
The lectures teach the classic neurodevelopmental methods:
- Bobath concept (neurodevelopmental treatment): the therapist's hands inhibit abnormal tone and patterns and guide normal movement and posture, using positioning, weight-bearing through the affected side and functional tasks. The professor recommends it for patients with higher rehabilitation potential.
- Brunnstrom approach: uses the synergies and primitive reflexes the patient already has, under voluntary control, to get movement going, then moves through the stages towards selective movement. Recommended for lower potential and early stages.
- PNF (Kabat): proprioceptive neuromuscular facilitation uses spiral and diagonal patterns, manual resistance, stretch and verbal cues to recruit more muscle.
Newer, task-oriented methods have more evidence:
- Task-specific training: practising the real task (reaching for a cup, standing up, walking) many times, in a meaningful setting, with feedback.
- Constraint-induced movement therapy: the good hand is put in a mitt for most of the waking day while the weak arm does hours of graded tasks. It overcomes learned non-use, and needs some active wrist and finger extension to start.
- Mirror therapy: the patient moves the good hand while watching its reflection where the weak hand is, which activates the motor areas for the affected side; it helps arm function and neglect a little.
- Gait training: treadmill with or without body-weight support, electromechanical and robotic devices, an ankle-foot orthosis or FES of the peroneal nerve for foot drop.
- Other: balance training, strength and aerobic training, virtual reality; brain stimulation (rTMS, tDCS) is not yet routine, as its evidence is still uncertain.
Walking aids follow simple rules: a stick or quad cane in the unaffected hand, moving with the affected leg. On stairs, up with the good, down with the bad: going up the strong leg leads, going down the weak leg goes first.
Physical modalities
| Modality | Why | Notes |
|---|---|---|
| Low-frequency electrical stimulation (NMES, FES) | contracts weak muscles; trains wrist extensors; FES of the peroneal nerve lifts the foot while walking | early stimulation of supraspinatus and deltoid may reduce shoulder subluxation |
| TENS | pain, especially shoulder pain | |
| Cryotherapy | lowers spasticity for some hours, so the muscle can be stretched and the antagonist trained | check sensation; sensory loss is common |
| Heat, peloids | relaxes muscle, eases pain | never on numb skin, as the patient cannot feel a burn |
| Hydrotherapy | warm water relaxes spastic muscle, buoyancy helps movement and balance | once continent and medically stable |
| Ultrasound | tissue extensibility before stretching | weak evidence |
Prevention of secondary complications
Many of the worst problems after stroke are not from the stroke itself but from lying still. They start in the first days, and prevention starts then too.
Positioning
The patient is turned at least every two hours and laid out against the spastic pattern: lying on the affected side (it brings feeling and attention to that side and leaves the good hand free), lying on the good side with the affected arm forward on a pillow, and on the back with the shoulder supported forward and the hand open. Sitting is upright and symmetrical, with the affected arm on a table or tray. Long periods in one position, and especially in a slumped half-sitting position, are avoided.
| Complication | Why | Prevention |
|---|---|---|
| Hemiplegic shoulder pain | subluxation, injury from handling, spasticity, shoulder-hand syndrome (a complex regional pain syndrome) | support the arm (tray, armrest), teach safe handling, no overhead pulleys, gentle range within pain, early FES |
| Spasticity and contractures | muscles held short | positioning, daily stretching, splints, early active movement, botulinum toxin when focal |
| Aspiration pneumonia | dysphagia, weak cough, lying flat | a swallow screen before any food, drink or tablet; sitting up to eat; breathing exercises, chest physiotherapy |
| Deep vein thrombosis, pulmonary embolism | a still, weak leg | early mobilisation, hydration; intermittent pneumatic compression in immobile patients (graduated stockings alone do not work); drug prophylaxis after ischaemic stroke where appropriate |
| Pressure ulcers | immobility, sensory loss, incontinence | turning, pressure-relieving mattress, skin checks, nutrition |
| Urinary problems | retention, incontinence, catheters | bladder training, avoiding long-term catheters, intermittent catheterisation for retention |
| Constipation, faecal incontinence | immobility, fluids, drugs | bowel programme, fluids, fibre |
| Falls and fractures | weakness, neglect, poor balance, bone loss on the paretic side | balance training, safe environment, aids, osteoporosis care |
| Depression, anxiety | common, about a third of patients | screening, psychological support, antidepressants when needed |
| Cardiovascular events, deconditioning | the same disease, inactivity | aerobic training, secondary prevention of stroke |
A multidisciplinary approach
Stroke is treated best in a stroke unit: a dedicated ward where a trained team works together. Stroke units save lives and leave more patients independent than general wards.
| Team member | Role |
|---|---|
| Physiatrist (PRM specialist) | assessment, goals, prescription, leading the rehabilitation plan, spasticity and pain treatment |
| Neurologist | diagnosis, acute treatment, secondary prevention |
| Physiotherapist (rehabilitator) | movement, balance, walking, positioning |
| Occupational therapist | daily activities, arm and hand, cognition in daily tasks, home adaptations |
| Speech and language therapist | swallowing, aphasia, dysarthria |
| Nurse | positioning, skin, bladder and bowel, carrying therapy into the day |
| Psychologist | mood, cognition, adjustment |
| Dietitian, social worker, orthotist | nutrition; benefits, home and work; orthoses |
| Patient and family | goals, practice outside therapy, care at home |
The team meets regularly, sets goals with the patient, and repeats the cycle: assessment, goal setting, intervention, evaluation, adjustment. After discharge there is follow-up and a home programme for life.
Check yourselfAnswer, then say how sure you were: a lucky guess still counts as a weak point.
1A nurse helps a man with a flaccid left arm, three days after a stroke, to sit up by pulling under his left armpit. What is the main risk?
2Five months after a stroke, a woman can extend her right wrist and fingers a little but uses only her left hand in daily life. Which method targets this problem most directly?
3What did the AVERT trial teach about mobilisation in the first day after stroke?
4A man with a right hemiparesis is learning to climb stairs with a stick and a rail. How should he go?
5A patient admitted with a stroke is drowsy and has a weak cough. Before he is given anything to drink, what must happen?