Post-Acute Care and Rehabilitation
First 24-72 hours
Priorities are airway and swallowing safety, mobilization, prophylaxis, and complication surveillance. Screen swallowing with a validated tool before any oral intake, including medications. Start subcutaneous DVT prophylaxis in immobile patients; use intermittent compression devices when anticoagulation is contraindicated. Position the head of bed at 30 degrees or less unless there is a reason to elevate, and begin low-dose mobilization once the patient is physiologically stable.
Neuroplasticity-driven therapy
Recovery depends on intensity, repetition, task specificity, and salience. Evidence-supported approaches include constraint-induced movement therapy for selected upper-extremity deficits, treadmill and gait training, task-specific practice, mirror therapy, and early supported discharge with multidisciplinary teams. Speech therapy addresses aphasia and dysarthria; occupational therapy addresses activities of daily living, neglect, and apraxia.
Preventing the complications that undo progress
Watch for shoulder subluxation and pain - support the hemiplegic arm and avoid overhead pulleys and aggressive range of motion. Screen for depression and anxiety, urinary retention, constipation, pressure injury, falls, spasticity, and seizures. Educate the patient and family about the affected side, hemi-inattention, and safety.
Traps: very early, high-dose mobilization within 24 hours has been associated with worse outcomes - do not confuse early mobilization with aggressive mobilization. Do not allow oral intake before a swallow screen. Do not neglect the affected limb by pulling on it during transfers.
Rule of thumb: pass the swallow screen before the first sip, first pill, or first bite.