Stroke: Rehabilitation and returning to normal life

The aim of rehabilitation is to help people

• regain independence,
• cope with any impairments and
• reduce paralysis, speech and memory problems, depression, and other effects.

It also helps them prepare for when they go home and return to normal life, and helps family members adjust.

The medical professionals working with the stroke patient discuss and set the rehabilitation goals with them. The goals depend on things like the severity of the impairments, what can be achieved and what the person’s main needs are.

Setting clear, realistic goals can help the person keep motivated during rehabilitation so they can get the most out of it. These goals may include things like going back to work, walking unaided or being able to do housework.

Our brains have the ability to change and adapt. They can create new connections between the nerves at any time, even at an advanced age. That means if one part of the brain stops working properly, another part can perform its function instead.

This flexibility (known as "neuroplasticity") makes it possible for our bodies to compensate for impairments like speech problems or paralysis. That doesn’t mean the impairments will definitely go away completely. But it is often possible to reduce them. Targeted training can activate the affected parts of the brain. This is a gradual process, usually starting with simple exercises, often with aids and the support of a therapist. When the person can manage these exercises, they can move on to more complex exercises with less help. This approach enables them to gradually regain their abilities or reduce any impairments. Generally speaking, the more intensive the training, the higher the chances of success.

Rehabilitation includes:

• Physical therapy/strength training: People who use a wheelchair or are bedridden might practice things likes getting up from a chair or bed and taking a few steps. Training to improve balance, strength and endurance can help people learn how to walk more steadily again. There are also exercises to improve arm and hand movement. They may involve using the affected arm more, for instance. The exercises can help prevent shoulder pain too.
• Speech therapy: Many people who have had a stroke have trouble forming sentences or finding words. Others speak unclearly or with a slur. They may also have problems swallowing. There are special exercises for these impairments.
• Occupational therapy: The aim of this therapy is to improve independent living skills. It involves practicing everyday skills like getting dressed or eating without help, as well as doing perception and concentration exercises. People who need special aids, like walking aids, can practice using them.
• Neuropsychological treatment: This psychotherapy approach was developed especially for people who have a brain injury. It helps them train things like memory, attention and perception. But it also helps them learn how to cope – both in practical and emotional terms – with limitations in their everyday lives.
• Nursing care: Care staff can help the person to carry out activities like eating, washing and (un)dressing. The nurses also show them what they can do for themselves despite their impairments.

Rehabilitation programs teach people exercises they can do on their own at home too. This is important because regular practice can have a positive effect even at a later stage.

A lot of people regain important abilities thanks to rehabilitation. Most improvements occur in the first six months after the stroke. Impairments can improve significantly after that too – especially in younger people. But some older people can regain abilities years after the stroke as well.

The chances of recovery mainly depend on which part of the brain was affected by the stroke, and how severe the stroke was. People who led quite an active life before the stroke also have better chances of recovery.

In Germany, the hospital makes the application and the arrangements to have you moved to a rehabilitation facility. This is done by staff from the hospital’s welfare service and discharge management team.

The application is made to your pension fund or health insurance fund. They approve three weeks of rehabilitation to start with. But this can be increased if necessary. The doctors there will advise you on whether you need longer.

There are two types of rehabilitation that are useful for people who have had a stroke:

• neurological rehabilitation
• geriatric rehabilitation

Neurological rehabilitation requires more sessions than geriatric rehabilitation does, and its main goal is to prepare the person to return to work. Geriatric rehabilitation is chiefly aimed at older people with a number of pre-existing conditions.

Sometimes, semi-residential or outpatient rehabilitation is an option too. Semi-residential rehabilitation involves attending a rehabilitation facility during the day but spending the evenings and weekends at home. Outpatient rehabilitation takes place in special centers where people go for their appointments. Only those who can look after themselves or have someone to look after them are eligible for semi-residential or outpatient rehabilitation.

Inpatient and semi-residential rehabilitation is usually followed up with outpatient rehabilitation. The facility’s welfare service will make the necessary arrangements before the person is discharged. They also check whether the person needs special equipment at home or whether changes will have to be made to their home. The outpatient care is then usually coordinated by the family doctor’s practice.

Some people are so ill or frail after their stroke that rehabilitation is not an option for them at all. In that case nursing staff will look after them. Palliative care might also be an option. The main aim then is to support the person during the last phase of their life and to minimize any health problems they have.

The situation after a stroke can vary greatly between different people. Some are very old and ill, and need nursing care more than anything else. In Germany, organizations such as welfare services (Sozialdienste) and nursing care information centers (Pflegeberatungsstellen) can help make the necessary arrangements. Depending on the circumstances, the person can be nursed in their own home or a care home. They have to apply to their long-term care insurer (Pflegekasse) for this care.

Other people are still of working age and want to get back to work after rehabilitation. There are various return-to-work paths they can take. In Germany, one possibility is the "Hamburg model," which involves planning a gradual return to work in consultation with the employer. A key part of this is looking to see what tasks the person can perform and where special support is needed. Workplace modifications and special equipment are also possible. It is important that the person doesn’t do too much and adjusts their workload to their ability – particularly at the beginning.

In Germany, local sports clubs run rehabilitation exercise classes, which people who’ve had a stroke can attend. These Rehasport classes are group sessions for endurance, strength, and coordination training. They include things like exercises, active games, and swimming. Doctors can prescribe Rehasport classes. Statutory health insurers then cover the costs for at least one to two years.

Further information about post-stroke rehabilitation in Germany can be obtained from Deutsche Schlaganfall-Hilfe (the German Stroke Foundation).