Stroke Recovery Timeline

Stroke recovery is a dynamic and often protracted process. Below we define the 4 phases of recovery, describe the typical timeframe it covers, characterize some of the key biological factors that dominate that phase, outline some canonical goals, and define the healthcare setting where treatment is typically rendered.

1. Hyperacute

The hyperacute phase of stroke recovery starts as early as symptom onset and continues out to around 48 hours. This phase of stroke recovery is dominated by trying to maintain the patient’s life while reperfusing areas of the nervous system, maintaining the viability of other neural structures that are at risk, and reducing the extent of cell death. While great strides have been made in reducing the impact of stroke, i.e. through pharmacologic interventions like tPA, in most cases, an inevitable outcome is the development of a hematoma which leads to cell death. This early phase of stroke recovery typically occurs in the inpatient hospital setting. This allows for the application of appropriate diagnostic tools and therapeutic interventions to be delivered.

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Goal: The primary goal of the hyperacute phase of stroke recovery is to keep the patient alive and minimize the extent to which nervous system structures are left without oxygen (ischemia).

2. Acute

The acute phase of stroke recovery starts around the same time as the hyperacute phase but extends out to around the 7 day mark. Biologically, this phase of stroke recovery is dominated by the natural inflammatory process which is critical to clear damaged tissue and metabolic byproducts that emerge from the injury. The acute beginning of scar formation. The Acute phase of stroke recovery is often initiated in the inpatient hospital setting. However, depending on the individual patient’s needs, they may be discharged to an inpatient rehabilitation setting, either a skilled nursing facility (SNF) or an inpatient rehabilitation hospital. The decision for selecting either inpatient setting is directed by a medical team, i.e. Physician, case manager, and Physical and Occupational Therapists. Unfortunately, a patient’s insurance also influences the selection of a setting as the setting must be willing to accept the third-party payers rates.

Goal: Medically, the primary goal is to reduce the impact of primary injury and reduce the probability of secondary injury responses, thereby minimizing the overall loss of viable neural structures. In this phase of recovery, provided hemodynamic stability is achieved rehabilitation can be initiated with the goal of leveraging endogenous plasticity to facilitate recovery.

3. Subacute

Typically, the subacute phase of stroke recovery occurs between 1 week and 3 to 6 months after onset of symptoms. Early in this phase the damage resulting from the primary injury and any secondary (responsive) processes should be slowing down and eventually subsiding. This phase is dominated early on by rapid spontaneous recovery due to endogenous plasticity. During this period, a heightened sensitivity to motor learning also makes it ideal for the delivery of focused rehabilitation. As a result, the typical stroke survivor spends much of this time (i.e. 5 days of therapy per week with up to 3 hours per day) either in an inpatient rehabilitation center or at an intensive outpatient rehabilitation setting.

Goal: The principal goal of this phase of recovery is to leverage endogenous plasticity to facilitate true ‘recovery’. To do this, a sufficiently high dose and intensity of rehabilitation is needed which is focused on a patient’s specific impairments.

4. Chronic

While definitions can vary, the chronic stroke recovery phase is typically defined as the period starting 6 months after onset of symptoms and can extend for the rest of a patient’s life. At this point, damage due to the primary injury and any secondary (responsive) processes should be complete. This results in a fluid-filled cyst where the stroke occured. Typically, recovery tends to plateau during this period revealing the likely scale of permanent disability. While improvements in function tend to slow down, they do not necessarily stop. There is a subtle but significant shift in the underlying driver of improvements away from recovery (i.e. restitution of normal structures) in favor of behavioral compensatory mechanisms. The vast majority of patients in this phase of recovery are delivered care in the outpatient setting. Occasionally, depending on the level of impairments and caregiver support, therapy is sometimes delivered in the patient’s home through home-health care rehabilitation.

Goal: Chronic phase goals are dominated by the desire to reduce impairments and improve function. While there is considerable evidence that neuronal plasticity can continue well into the chronic stage of stroke to improve motor control, it often takes considerable effort to achieve adequate doses that are sufficient to lead to improvements in function. Although compensatory movements may help patients perform tasks in the short term, the presence of compensation may be associated with long-term problems such as reduced range of joint motion and pain and lead to a pattern of learned nonuse that limits their capacity to gain capabilities later.

References: Bernhardt, Julie, Kathryn S. Hayward, Gert Kwakkel, Nick S. Ward, Steven L. Wolf, Karen Borschmann, John W. Krakauer et al. “Agreed definitions and a shared vision for new standards in stroke recovery research: the stroke recovery and rehabilitation roundtable taskforce.” International Journal of Stroke 12, no. 5 (2017): 444-450.