The acute stage of stroke encompasses the first 24 h to 1 week following the onset of the stroke. During this initial phase, the primary focus is on medical stabilization and preventing further brain damage (99). Immediate medical interventions are crucial, including measures to restore blood flow, such as the administration of tissue plasminogen activator (tPA) for ischemic strokes or surgical procedures to address hemorrhagic strokes (100). Early rehabilitation efforts aim to prevent complications, such as deep vein thrombosis, pressure sores, and contractures. Gentle mobilization, proper positioning, and passive range of motion exercises are implemented to maintain some level of physical function. Basic activities of daily living (ADL) training, including assistance with eating, dressing, and personal hygiene, are introduced to help patients maintain a degree of independence. Psychological support is also essential at this stage to help patients and their families cope with the emotional impact of the stroke (101).

The subacute stage occurs from 1 week to three to 6 months post-stroke. This phase is marked by more intensive rehabilitation efforts aimed at promoting neurological recovery and improving functional abilities (102). During the subacute stage, patients typically engage in comprehensive rehabilitation programs that include physical therapy, occupational therapy, and speech and language therapy. Physical therapy focuses on improving strength, coordination, balance, and mobility through exercises and activities tailored to the patient’s needs (103). Occupational therapy helps patients regain the ability to perform daily tasks, such as dressing, bathing, and cooking, by using techniques like constraint-induced movement therapy (CIMT) and dual-task training (104). Proprioceptive training is also incorporated to enhance the patient’s sense of body position and movement (105). Speech and language therapy continues to address communication and swallowing difficulties (106). Psychological counseling and support remain vital to address any emotional and cognitive challenges that arise during this phase of recovery (107).

The chronic stage of stroke begins 6 months after the initial event and extends indefinitely. During this phase, the focus shifts to long-term rehabilitation and the management of any residual disabilities. The goal is to maintain and further improve functional abilities while helping patients adapt to their long-term needs (55). Rehabilitation interventions in the chronic stage often include community-based programs, which provide ongoing therapy and support. Advanced therapies such as robot-assisted therapy and virtual reality training are used to enhance motor skills and cognitive functions (108). Functional electrical stimulation (FES) may be employed to improve muscle function, and mirror therapy can be used to create the illusion of movement in the affected limb (109). Cognitive rehabilitation activities are designed to improve memory, attention, and problem-solving skills. Aerobic exercises and hydrotherapy are included to improve cardiovascular health and overall fitness (70). Music therapy can be beneficial for enhancing mood and cognitive functions (110). Long-term psychological support is crucial for helping patients adjust to their new normal and maintain motivation for continued recovery (111).

In the crucial hours immediately after a stroke, the introduction of early rehabilitation initiatives holds profound significance. These pivotal interventions, instated within the initial 24 to 48 h following the stroke event, form the cornerstone of the recovery process (118). Their primary objectives encompass preventing potential complications, initiating the rehabilitation trajectory, and laying the essential groundwork for optimal recovery (119).

Passive range-of-motion exercises emerge as fundamental components even during the acute phase post-stroke. These gentle movements administered to the affected limbs serve as a safeguard, preserving joint flexibility and thwarting the onset of muscle contractures. This preventive measure is instrumental in mitigating the risks associated with long-term impairments that could impede the recovery process (120, 121). Early mobilization takes precedence as a pivotal strategy in acute rehabilitation. Encouraging and facilitating patients to engage in sitting exercises, standing movements, and, when feasible, undertaking short walks constitute early mobilization efforts (71). Beyond mitigating muscle deconditioning, these early mobilization initiatives significantly mitigate the likelihood of complications like deep vein thrombosis and pressure ulcers, essential for promoting a conducive environment for recovery (122, 123). Sensory stimulation techniques, involving tactile, auditory, or visual stimulation, are employed to arouse and activate affected senses. This early engagement of the senses aims to jumpstart neural plasticity and sensory reawakening in the specific brain regions impacted by the stroke event (124, 125). While seemingly straightforward, these early rehabilitation initiatives wield a profound impact. Their implementation is consistently validated by research, underscoring their pivotal role in shaping the trajectory of recovery for stroke survivors.

In the acute phase of stroke rehabilitation, the focus sharply narrows to addressing mobility and functional impairments. This critical phase aims to reestablish lost capabilities, enhance balance, coordination, and restore independence in daily activities (Figure 2). Physiotherapy interventions form the backbone of efforts to regain mobility. Gait training, strength-building exercises, and balance drills orchestrated by physiotherapists are instrumental in improving motor function. These specialized exercises and techniques, often personalized to the individual’s condition, actively work toward ameliorating gait abnormalities. The integration of assistive devices and adaptive strategies further facilitates safe and effective movement (126, 127). Occupational therapy takes center stage in reinstating functionality in ADLs. Occupational therapists guide patients through essential tasks, such as dressing, grooming, feeding, and home management. The focus lies in enabling patients to regain independence in these pivotal daily activities, promoting autonomy and self-sufficiency (128). Task-specific training, an integral component of acute rehabilitation, involves engaging patients in activities tailored precisely to their deficits. By replicating real-life situations, this method fosters neural reorganization and functional recovery. These activities, meticulously designed to confront the unique challenges posed by the stroke, play a pivotal role in retraining the brain and restoring lost functionalities (56, 129). This acute phase of rehabilitation, deeply rooted in tailored interventions and guided exercises, serves as the foundation upon which subsequent recovery efforts are built. By addressing mobility and functional impairments strategically, this phase contributes significantly to restoring independence and enhancing the quality of life for stroke survivors (87).

Integrating rehabilitation seamlessly into acute care settings is a fundamental aspect of providing comprehensive stroke care. This integration involves merging rehabilitation strategies into the acute medical management plan, ensuring a cohesive approach to address immediate medical needs alongside rehabilitation goals (130). Early identification and team collaboration are pivotal in this integration. Identifying rehabilitation needs promptly and assembling a multidisciplinary team comprising neurologists, physiatrists, nurses, therapists, and social workers facilitates a comprehensive assessment. This collaborative effort allows for a simultaneous evaluation of rehabilitation requirements in tandem with acute medical interventions (131). Tailoring rehabilitation goals forms the cornerstone of the integrated approach. Setting specific, measurable, achievable, relevant, and time-bound (SMART) objectives is crucial. These objectives, personalized to the patient’s condition, aim to optimize functional recovery while concurrently addressing immediate medical concerns. This tailored framework for rehabilitation forms the bedrock of a responsive and dynamic rehabilitation plan (132). Continuous monitoring and adjustment of rehabilitation strategies are essential components of this integrated model. Continuous evaluation of the patient’s response to rehabilitation interventions enables real-time adjustments. This adaptive approach ensures that rehabilitation strategies remain responsive to the patient’s evolving needs and medical condition, fostering a flexible and patient-centric rehabilitation process (133, 134). Integrating rehabilitation into acute care represents a paradigm shift, acknowledging the symbiotic relationship between immediate medical interventions and the imperative need for rehabilitative efforts. This holistic approach not only kickstarts the rehabilitation journey early on but also ensures a coordinated and comprehensive care plan for stroke survivors (19, 135).

Physical therapy (PT) stands as a cornerstone within stroke rehabilitation, encompassing a multifaceted approach aimed at restoring mobility, enhancing motor function, and mitigating physical impairments. It serves as an integral component throughout the continuum of stroke care, spanning from acute management to long-term recovery (136, 137). Upon initial assessment, physical therapists meticulously evaluate the individual’s functional abilities, motor impairments, and specific limitations resulting from the stroke. Based on this assessment, personalized rehabilitation plans are crafted, and tailored to address the unique needs and goals of each patient. These plans are dynamic, evolving with the patient’s progress and changing requirements (138, 139). Gait training assumes a crucial role in PT for stroke survivors, focusing on restoring and optimizing walking patterns.

Therapists employ various techniques, from treadmill-based training to over-ground walking practice, concentrating on improving balance, strength, and coordination (140). Advanced technologies such as robotic-assisted gait training or body-weight-supported treadmill training may be utilized to augment the rehabilitation process. Emphasis is placed on re-establishing a safe and functional gait to enable increased independence in daily activities (141). PT interventions encompass a range of exercises designed to enhance muscle strength, flexibility, and coordination. Targeted exercises, customized to address specific muscle groups affected by the stroke, aid in motor recovery. Therapists utilize resistance training, functional activities, and neuromuscular re-education to promote muscle activation and facilitate movement in impaired limbs (142, 143). Therapists employ various balance exercises and proprioceptive activities to improve balance and coordination, essential for preventing falls and enabling functional mobility. These exercises often involve challenging the patient’s stability in a controlled environment to enhance balance reactions and postural control (144). Moreover, to mitigate the risk of secondary complications such as joint contractures and stiffness, therapists incorporate range-of-motion exercises. These gentle movements aim to preserve joint flexibility, prevent musculoskeletal issues, and facilitate ease of movement in affected limbs (145, 146). PT extends beyond clinical settings, encompassing functional training and home modification recommendations. Therapists collaborate with patients to simulate real-life scenarios, practicing activities crucial for daily living. Additionally, they provide guidance on adapting home environments and suggesting assistive devices and modifications to enhance accessibility and safety within the home setting (147, 148). Physical Therapy, as a core element of stroke rehabilitation, not only targets physical impairments but also promotes functional independence, enabling individuals to regain confidence and improve their overall quality of life following a stroke.

Occupational therapy (OT) within stroke rehabilitation is a pivotal modality focused on restoring independence in daily activities, re-establishing functional abilities, and promoting engagement in meaningful life roles. Tailored to each individual’s needs and goals, OT interventions span various domains to facilitate a smoother transition from impairment to autonomy (149, 150). Occupational therapists conduct comprehensive assessments to gauge the impact of stroke on an individual’s ability to perform daily tasks. These assessments help formulate personalized rehabilitation plans, targeting specific deficits in ADLs, instrumental activities of daily living (IADLs), work-related tasks, and leisure activities (151, 152). OT interventions primarily revolve around retraining and adapting ADLs. Therapists employ task-oriented training to facilitate independence in self-care activities such as grooming, bathing, dressing, toileting, and feeding. Adaptive strategies, environmental modifications, and the use of assistive devices are integrated to maximize functional independence and participation in daily routines (153, 154). Recovery of upper limb function is a key focus within OT. Therapists utilize exercises targeting hand-eye coordination, fine motor control, and dexterity. Techniques like constraint-induced movement therapy (CIMT), mirror therapy, and graded motor imagery are employed to encourage the use of the affected limb and improve its function (155). OT extends its scope to support community reintegration and vocational pursuits. Therapists assist individuals in transitioning back into community life by providing guidance on accessing community resources, public transportation, and social participation. Vocational rehabilitation focuses on adapting work environments, modifying job tasks, and exploring adaptive technologies to facilitate a return to work or engagement in meaningful productive activities (156, 157).

Occupational therapists address cognitive impairments and sensory deficits that impact daily functioning. Strategies are implemented to improve attention, memory, executive functions, and problem-solving skills necessary for effective task performance. Sensory integration techniques help individuals process sensory information effectively, enhancing their ability to engage in meaningful activities (158). Collaborating with individuals and their families, OTs recommend modifications in the home environment to promote safety, accessibility, and independence. Suggestions for adaptive equipment and assistive devices are provided to facilitate ease in performing tasks and to compensate for functional limitations (159). OT, as an integral part of stroke rehabilitation, focuses on enabling individuals to regain independence and participation in activities essential to their daily lives, fostering a sense of accomplishment and self-sufficiency post-stroke.

Speech and language therapy (SLT) is a critical component of stroke rehabilitation, encompassing a diverse range of interventions tailored to address communication and swallowing difficulties. These interventions aim to restore functional communication abilities and ensure safe swallowing, significantly impacting an individual’s quality of life post-stroke (39). Speech-language pathologists conduct comprehensive assessments to evaluate the extent of communication impairments and swallowing difficulties post-stroke. These assessments form the basis for individualized treatment plans that address specific deficits and goals (160). SLT interventions for speech articulation aim to improve clarity, intelligibility, and pronunciation. Therapists utilize exercises targeting oral-motor coordination, breath control, and vocal exercises to enhance speech production (161). Techniques such as articulation drills, repetition exercises, and tongue-strengthening exercises aid in improving speech intelligibility (162). Language therapy focuses on improving language comprehension and expression abilities. Therapists employ activities like word-finding exercises, storytelling, and comprehension tasks to enhance language skills. Strategies aim to rebuild vocabulary, sentence construction, and overall language fluency (163).

SLT addresses cognitive-communication deficits resulting from stroke, including impairments in problem-solving, reasoning, and social communication skills. Therapists use tasks such as conversation practice, problem-solving scenarios, and pragmatic language exercises to improve overall communication abilities (164). Swallowing difficulties, known as dysphagia, are common post-stroke. SLT interventions target these issues to ensure safe and efficient swallowing. Therapists employ various exercises to improve muscle coordination and swallowing reflexes (165). Strategies like modified diets, swallowing maneuvers, and postural adjustments are introduced to minimize the risk of aspiration and enhance swallowing function (166). For individuals with severe communication impairments, SLT involves introducing augmentative and alternative communication (AAC) strategies. These may include communication boards, speech-generating devices, or apps that enable individuals to express themselves effectively, compensating for speech difficulties (167). SLT involves educating families and caregivers about communication strategies and techniques to facilitate effective communication with the individual post-stroke. Training in supportive communication approaches fosters better understanding and interaction within the home environment (168). SLT, as a crucial element in stroke rehabilitation, aims to restore communication abilities and ensure safe swallowing, empowering individuals to engage more fully in social interactions and daily activities. A systematic review and meta-analysis by Chiaramonte and Vecchio (169) demonstrated the efficacy of speech rehabilitation in treating dysarthria among stroke survivors. The study observed notable enhancements in essential acoustic parameters, including alternating and sequential motion rates (AMR and SMR) and maximum phonation time, post-speech therapy. These parameters are vital for evaluating and managing dysarthria as they are directly linked to motor control necessary for speech production. Utilizing tools such as the Multi-Dimensional Voice Program (MDVP) and PRAAT software for acoustic analysis enables an objective measurement of improvements in patients’ speech intelligibility and supports targeted therapeutic interventions. Notably, techniques that increase jaw movement, promote louder speech, and expand vowel space area have been found to significantly enhance speech clarity and intelligibility. Incorporating these detailed assessments and targeted interventions into SLT programs can lead to more effective rehabilitation outcomes, thereby improving communication abilities and overall quality of life for stroke survivors (169).

Cognitive rehabilitation plays a vital role in stroke recovery, focusing on addressing cognitive impairments such as memory deficits, attention issues, and executive function difficulties. This multifaceted approach aims to restore and enhance cognitive abilities, ultimately promoting independence and improving the individual’s quality of life post-stroke (170). Cognitive rehabilitation begins with a comprehensive assessment of cognitive functions post-stroke. Therapists evaluate memory, attention, problem-solving, and executive function to identify specific deficits. Based on this assessment, tailored interventions are designed to address individual needs (88). Therapists employ various memory-enhancing techniques to improve memory recall and retention. These strategies may include mnemonic techniques, spaced-repetition exercises, memory games, and the use of memory aids like calendars or notebooks. By practicing memory recall, individuals can strengthen their ability to retain and retrieve information (171, 172). Interventions targeting attention deficits involve exercises that aim to improve different aspects of attention, including sustained attention, selective attention, and divided attention (173). Therapists utilize tasks requiring sustained focus, attentional drills, and multitasking activities to enhance attentional abilities and reduce distractibility (174). Cognitive rehabilitation addresses deficits in executive functions such as planning, problem-solving, and decision-making. Therapists employ tasks that require organization, time management, and prioritization to enhance cognitive flexibility and executive control. Strategies focus on breaking tasks into manageable steps and implementing problem-solving techniques (175). For individuals experiencing cognitive-communication deficits, therapists introduce strategies that enhance communication effectiveness. Techniques may involve using visual aids, simplifying information, and employing structured communication methods to aid comprehension and expression (176). Interventions extend to practicing functional tasks relevant to daily life. Therapists guide individuals through activities that replicate real-world scenarios, such as meal planning, managing finances, or using public transportation. Task-specific training helps individuals adapt to challenges they might encounter in their daily routines (177). Therapists collaborate with individuals to develop compensatory strategies and routines to cope with cognitive deficits. Additionally, recommendations for environmental modifications, such as organizing living spaces or implementing memory aids, assist individuals in managing daily tasks more effectively (178). Cognitive rehabilitation within stroke rehabilitation focuses on empowering individuals to adapt and compensate for cognitive impairments, enhancing their ability to perform daily activities independently and facilitating a smoother reintegration into their daily routines post-stroke.

Stroke rehabilitation aims to restore balance and autonomy in ADL through a variety of targeted exercises. Proprioceptive training, which focuses on improving body position awareness, is crucial for enhancing balance and coordination. Techniques such as balance boards, stability exercises, and sensory re-education are employed to stimulate proprioceptive feedback, promoting better motor control and reducing fall risk (105).

Dual-task exercises, which require patients to perform a motor task while simultaneously engaging in a cognitive task, have shown significant benefits in stroke recovery. These exercises not only improve physical function but also enhance cognitive processing, which is often impaired in stroke survivors. For instance, walking while counting backward or performing a physical task while responding to questions helps integrate cognitive and motor skills, leading to improved overall function (179, 180).

Goal-oriented exercises involve setting specific, measurable, achievable, relevant, and time-bound (SMART) goals that align with the patient’s individual needs and capabilities. These exercises foster motivation and adherence to the rehabilitation program (181). By focusing on personal goals, such as dressing independently or walking a certain distance, patients are more likely to stay engaged and committed to their recovery process. Research has shown that goal-setting significantly improves outcomes in stroke rehabilitation by providing clear targets and enhancing patient autonomy (182).

Incorporating proprioceptive training, dual-task exercises, and goal-oriented exercises into stroke rehabilitation programs offers a comprehensive approach to improving balance and autonomy in ADL. Proprioceptive training enhances sensory feedback and coordination, dual-task exercises improve multitasking abilities and overall functional performance, and goal-oriented exercises ensure that rehabilitation is relevant and motivating for the patient. Together, these interventions address both the physical and cognitive challenges faced by stroke survivors, leading to more effective rehabilitation outcomes. Future research should continue to explore the optimal strategies for integrating these approaches to maximize their benefits for stroke patients.

Spasticity resulting from strokes poses considerable hurdles to motor function and daily tasks for those affected. Botulinum toxin type A (BoNT-A) injection has become the preferred treatment for localized spasticity, especially among stroke survivors, owing to its established effectiveness, reversible nature, and minimal risk of complications. The treatment of upper motor neuron syndrome, marked by spasticity and excessive muscle activity, requires strategies to alleviate spasticity-related issues and forestall further complications (183). BoNT-A treatment has become a crucial therapeutic approach, especially for localized spasticity in individuals who have had strokes. Research exploring the effectiveness of elevated doses of BoNT-A (exceeding usual guidelines) in post-stroke spasticity has shown encouraging outcomes (184). Despite initial worries about potential systemic side effects, most patients encountered substantial decreases in spasticity without encountering severe issues (185, 186). Although elevated doses of BoNT-A demonstrated effectiveness in spasticity reduction, instances of adverse effects, including contralateral weakness and systemic complications, were observed in certain cases (187). It is essential to carefully assess injection frequency, dilution volumes, and the possibility of antibody formation to minimize the likelihood of adverse events (188). The results highlight the efficacy of elevated doses of BoNT-A in managing post-stroke spasticity, especially in scenarios involving significant muscle hypertonia (189). Nonetheless, meticulous patient selection, accurate injection methodologies, and vigilant monitoring for adverse effects are crucial to enhancing treatment efficacy and upholding patient well-being. Research findings indicate the potential benefits of increased BoNT-A doses in mitigating spasticity and enhancing functional recovery among stroke survivors (190). Additional investigations are needed to clarify the most effective dosing regimens, improve injection methodologies, and assess the long-term safety and effectiveness in broader patient populations.

Technological advancements, particularly in robotics, have dramatically transformed the landscape of stroke rehabilitation, ushering in innovative approaches to enhance motor recovery, functional abilities, and overall quality of life for individuals affected by stroke (191). In upper limb rehabilitation, robotics play a pivotal role by offering precise and intensive therapy through devices like exoskeletons and end-effector robots. These devices provide tailored exercises, guiding patients through movements aimed at improving motor control, strength, and the range of motion in affected arms and hands. This focused approach allows therapists to customize rehabilitation plans based on specific impairments, fostering more targeted and impactful interventions (192, 193). Gait training, crucial for restoring walking abilities post-stroke, benefits significantly from robotic systems. Exoskeletons and treadmill-based robots assist individuals by providing mechanical support and guidance during walking exercises (194). These devices help in relearning proper gait patterns, correcting asymmetries, and improving balance and stride length. The real-time feedback offered by these systems enhances motor learning, aiding in the retraining of gait patterns (195). One of the significant advantages of robotic-assisted therapy lies in its ability to offer task-specific training. Therapists can replicate real-life activities through these systems, allowing stroke survivors to practice movements required for daily tasks. This tailored approach fosters neuroplasticity, encouraging the brain to adapt and rewire neural connections to facilitate improved movement patterns (196).

Additionally, these robotic systems provide therapists with real-time feedback and monitoring capabilities. They track performance metrics such as range of motion, force exertion, and movement accuracy. This data empowers therapists to assess progress accurately, modify therapy intensity, and customize treatment plans according to individual responses, ensuring optimized rehabilitation outcomes (197). The advent of portable and user-friendly robotic devices has extended the reach of rehabilitation beyond clinical settings. Home-based rehabilitation using these systems enables stroke survivors to continue their therapy under professional guidance. This continuity in therapy enhances accessibility and adherence to treatment, contributing to sustained recovery (198). Furthermore, the integration of adaptive algorithms powered by machine learning and artificial intelligence tailors rehabilitation interventions to individual needs. These algorithms analyze patient responses in real-time, allowing for adjustments in therapy parameters to maximize the effectiveness of rehabilitation protocols (199).

The interactive nature of robotic technologies in stroke rehabilitation engages patients through gamified exercises and interactive interfaces. This enhanced engagement motivates individuals to actively participate in therapy sessions, promoting adherence and ultimately contributing to improved outcomes and functional recovery (200). However, it is essential to acknowledge certain limitations associated with the use of robotics in rehabilitation. While robotics offer precise and intensive therapy, some challenges need to be addressed. One such limitation is the cost involved in acquiring and maintaining robotic systems, which may pose financial barriers to widespread adoption. Moreover, in certain usage protocols, such as assistive modes, there is a risk of decreased effort or attention from patients during training sessions. This decrease in engagement could potentially impact the effectiveness of rehabilitation outcomes. Therefore, it is crucial for therapists to carefully monitor patient participation and motivation levels during robotic-assisted therapy to ensure optimal results (201–204). Despite these challenges, the benefits of robotic systems in stroke rehabilitation are considerable. Overall, while acknowledging the limitations, robotics in stroke rehabilitation represent a promising frontier in enhancing motor recovery and functional independence. These advancements pave the way for more personalized, engaging, and effective interventions, offering hope for improved rehabilitation outcomes for stroke survivors.

Technological advancements in virtual reality (VR) and augmented reality (AR) have profoundly impacted the landscape of stroke rehabilitation, offering immersive, interactive, and personalized interventions that significantly contribute to the recovery process (205).

Within stroke rehabilitation, VR therapy creates computer-generated environments that simulate real-life scenarios. These environments immerse patients in interactive exercises tailored to their specific rehabilitation needs. VR-based tasks focus on improving motor functions, cognitive abilities, and balance (206). For instance, individuals can engage in upper limb exercises or practice balance-related activities within a controlled virtual setting. By replicating real-world scenarios, VR therapy stimulates neuroplasticity and motor learning, aiding in functional recovery (207).

Augmented reality (AR) enhances rehabilitation by overlaying digital information onto the real world. AR applications provide real-time visual cues or instructions during exercises, aiding stroke survivors in performing movements accurately and safely (208). For example, a stroke survivor practicing arm movements may receive visual guidance overlaid onto their affected limb, promoting correct positioning and motion execution. AR enhances spatial awareness and motor planning, facilitating better task performance (209).

In cognitive rehabilitation, VR and AR interventions extend beyond physical movements to address deficits in attention, memory, and executive function. Gamified tasks and simulations challenge cognitive skills, stimulating neural adaptation and functional improvement (210). These technologies offer engaging and interactive cognitive exercises, fostering mental stimulation and promoting cognitive recovery post-stroke (211). Moreover, VR and AR applications allow stroke survivors to simulate functional tasks in a controlled virtual environment. Patients can practice activities such as cooking, shopping, or navigating public spaces within the safety of a virtual setting. These simulations offer a platform for individuals to relearn and regain confidence in performing daily tasks, preparing them for real-life scenarios and promoting independence (212, 213).

However, it is crucial to recognize that the applicability of VR therapy may vary among stroke survivors. Factors such as cognitive abilities, physical impairments, and individual preferences need to be considered when determining the suitability of VR interventions for a particular patient. While VR therapy holds tremendous potential for many individuals, it may not be suitable for everyone. Therefore, a comprehensive assessment on a case-by-case basis is essential to ensure that VR therapy is appropriately tailored to meet the unique needs and capabilities of each stroke survivor (214, 215).

Despite the need for individualized assessment, VR and AR applications have demonstrated significant potential to enhance motivation and engagement during rehabilitation sessions. The immersive nature of these interventions captures individuals’ attention, encouraging active participation in therapy. The interactive and enjoyable aspects of VR and AR contribute to increased adherence and consistency in rehabilitation exercises, positively impacting recovery outcomes. Overall, while recognizing the transformative impact of VR and AR technologies on stroke rehabilitation, it is essential to assess their applicability on a case-by-case basis. By conducting individualized assessments and tailoring interventions to meet the unique needs of each patient, therapists can maximize the effectiveness of VR and AR applications in promoting motor, cognitive, and functional recovery for stroke survivors (56, 216, 217).

Technological advancements in neurostimulation techniques have emerged as promising interventions within the realm of stroke rehabilitation, seeking to modulate neural activity, induce neuroplastic changes, and ultimately enhance recovery outcomes for individuals impacted by stroke.

One of the challenges in stroke rehabilitation is the absence of standardized guidelines for the timing of initiating rehabilitation programs. The timing of rehabilitation can significantly influence recovery outcomes, yet there is considerable variability in clinical practice regarding when to start specific rehabilitation interventions.

The initiation of rehabilitation can vary based on several factors, including the type of stroke, the severity of the stroke, patient comorbidities, and the specific rehabilitation protocols being used. Some rehabilitation programs advocate for early initiation, typically within the first few days after a stroke, while others may recommend waiting until the patient is more medically stable. Early rehabilitation, which often begins within the first 24 to 48 h after stroke onset, aims to capitalize on the brain’s heightened plasticity during the acute phase. This approach can help prevent complications such as muscle atrophy and joint contractures and can improve functional outcomes (101). However, it requires careful monitoring to avoid overexertion and other risks. In contrast, some protocols suggest delaying the start of intensive rehabilitation until the subacute phase, typically 1 to 2 weeks post-stroke. This delay allows for better medical stabilization and assessment of the patient’s overall condition (247). Furthermore, the lack of standardized timing affects various rehabilitation programs differently. Physical therapy and early mobilization are often encouraged, but the intensity and type of exercises may vary based on the patient’s initial response and stability (123). The timing for starting occupational therapy can depend on the patient’s ability to participate in ADLs and cognitive readiness (248). Moreover, the initiation of speech and language therapy may be contingent on the patient’s neurological status and ability to engage in communication exercises (101). The variability in the initiation of rehabilitation programs underscores the need for standardized guidelines that can provide a framework for clinicians. Developing such guidelines would involve comprehensive research to determine the optimal timing for different rehabilitation interventions. Additionally, these guidelines should consider individual patient factors, such as age, comorbidities, and stroke severity. Collaboration among healthcare providers is also essential to establish a consensus on best practices. Thus, Addressing the lack of standardized timing for stroke rehabilitation initiation is crucial for improving patient outcomes. Establishing evidence-based guidelines can help ensure that patients receive timely and effective rehabilitation, tailored to their specific needs and conditions. Future research should focus on identifying the most effective timelines for various rehabilitation interventions to create a standardized approach that can be widely adopted in clinical practice.

Access to comprehensive rehabilitation services remains a substantial challenge in stroke care. Geographical disparities, especially in rural or remote areas, often limit access to specialized rehabilitation centers and skilled healthcare professionals (249). Moreover, socioeconomic factors and financial constraints can impede access to rehabilitation, particularly for individuals with limited insurance coverage or financial resources (249). Addressing these challenges requires innovative approaches, such as telemedicine and mobile health solutions, to extend rehabilitation services beyond traditional clinical settings (250). Tele-rehabilitation programs, leveraging technology for remote assessment and therapy delivery, have shown promise in improving access to rehabilitation for underserved populations (251). Initiatives promoting community-based rehabilitation and partnerships with local healthcare providers play a crucial role in bridging the access gap, and ensuring equitable delivery of stroke rehabilitation services (252).

Stroke patients are particularly vulnerable to infections during their hospital stay due to a combination of factors such as immobility, impaired swallowing (dysphagia), weakened immune function, and the need for invasive procedures (253). These infections can significantly impact patient outcomes, prolong hospitalization, and increase healthcare costs. The most common infections encountered during hospitalization of stroke patients include pneumonia, urinary tract infections (UTIs), and bloodstream infections (254).

Pneumonia is one of the most frequent complications in stroke patients, particularly those with dysphagia, which is difficulty in swallowing. Aspiration pneumonia occurs when food, liquid, or saliva is inhaled into the lungs instead of being swallowed into the esophagus. This risk is heightened in patients who have had a stroke because the neurological impairment can affect the muscles involved in swallowing (255). Pneumonia in stroke patients can lead to severe respiratory issues and prolong recovery times (256). Preventative measures include early assessment and management of swallowing difficulties, the use of thickened liquids, and positioning strategies during feeding to reduce the risk of aspiration. Urinary tract infections (UTIs) are another common complication in stroke patients. Factors contributing to UTIs include the use of urinary catheters, which are often necessary due to incontinence or mobility issues post-stroke. Catheter-associated urinary tract infections (CAUTIs) are a significant concern because they can lead to more serious systemic infections, including sepsis (257). Preventing UTIs involves careful catheter care, minimizing catheter use, and removing catheters as soon as possible. Hydration, proper hygiene, and regular monitoring for signs of infection are also crucial. Bloodstream infections, including central line-associated bloodstream infections (CLABSIs), can occur in stroke patients, especially those who require intravenous therapy or other invasive procedures. These infections can escalate into sepsis, a life-threatening response to infection, further complicating the patient’s recovery (258). To prevent bloodstream infections, healthcare providers must adhere to strict aseptic techniques during the insertion and maintenance of central lines and other invasive devices. Regular monitoring and prompt treatment of any signs of infection are essential.

Preventing infections in stroke patients requires a comprehensive and proactive approach. Encouraging early movement and physical therapy to reduce the risks associated with prolonged immobility, such as pneumonia and pressure ulcers. Mobilization helps improve circulation and lung function, reducing the likelihood of infections (256). Performing timely evaluations of swallowing ability to identify patients at risk for aspiration pneumonia. Interventions might include dietary modifications, swallowing exercises, and the use of thickened liquids (255). Implementing protocols to ensure the proper use and maintenance of urinary catheters. This includes adhering to guidelines for catheter insertion, ensuring cleanliness, and removing catheters as soon as they are no longer necessary to reduce the risk of CAUTIs (257). Promoting stringent hand hygiene practices among healthcare providers and visitors to minimize the transmission of pathogens in the hospital environment (258). Using antibiotics judiciously to prevent the development of antibiotic-resistant bacteria and reduce the risk of adverse reactions. This involves selecting the appropriate antibiotic and duration of treatment based on the specific infection and patient condition (257). Infections are a significant risk for stroke patients during hospitalization, contributing to higher morbidity and mortality rates. By implementing targeted preventive measures and closely monitoring patients, healthcare providers can reduce the incidence of infections and improve overall outcomes. Effective infection control practices are essential to ensure the best possible recovery for stroke patients.

The heterogeneity of stroke-related impairments and the diverse needs of stroke survivors pose challenges in tailoring rehabilitation interventions. Standardized approaches may not adequately address the unique complexities of everyone’s recovery journey (47). Personalized rehabilitation plans that consider specific impairments, functional goals, cognitive abilities, and psychosocial factors are essential. Integrating advanced technologies, such as artificial intelligence (AI) and machine learning, into rehabilitation protocols enables the customization of interventions based on real-time patient data and responses (199, 259). Wearable devices and sensor-based technologies provide objective measures, facilitating the monitoring of progress and the adaptation of rehabilitation strategies according to individual needs (260). Establishing a framework for personalized rehabilitation that combines clinical expertise with technological advancements holds significant potential in optimizing outcomes for stroke survivors.

Effective stroke rehabilitation requires seamless collaboration among diverse healthcare professionals, each contributing specialized expertise. However, achieving interdisciplinary collaboration poses challenges in terms of communication, coordination, and shared decision-making among multidisciplinary teams (261). Enhancing collaboration necessitates specialized training programs that emphasize interdisciplinary skills, fostering a shared understanding of stroke rehabilitation across disciplines. Training initiatives that promote team-based care, communication strategies, and shared decision-making frameworks are pivotal in overcoming barriers to collaboration (262). Moreover, establishing interprofessional education programs during healthcare training cultivates a collaborative mindset among future healthcare providers. Encouraging interdisciplinary rounds, case conferences, and joint care planning sessions facilitate cohesive care delivery, optimizing rehabilitation outcomes for stroke survivors (262).

In navigating these challenges, there exist promising opportunities to revolutionize stroke rehabilitation. By addressing access disparities, individualizing care, and fostering interdisciplinary collaboration, the stroke rehabilitation landscape can evolve to provide more comprehensive, patient-centered, and effective care for stroke survivors. Continued innovation, research, and collaboration across healthcare sectors hold the potential to significantly enhance stroke rehabilitation outcomes in the future.

The future of stroke rehabilitation lies in advancing personalized approaches tailored to the specific needs and characteristics of each individual. Embracing innovative technologies, such as artificial intelligence and machine learning algorithms, holds immense promise in developing more sophisticated and adaptive rehabilitation protocols (19). These technologies can analyze vast datasets, including genomic, neuroimaging, and behavioral information, to create individualized treatment plans. Moreover, exploring the integration of virtual reality, augmented reality, and gamification strategies can further enhance engagement and motivation in personalized rehabilitation programs (263). The future direction emphasizes a shift towards precision medicine in stroke rehabilitation, catering treatments uniquely to each patient’s biological, cognitive, and psychosocial profile.

Understanding and leveraging neuroplasticity principles are at the forefront of future stroke rehabilitation strategies. Emphasizing interventions that harness the brain’s inherent ability to reorganize and adapt following injury is crucial. Innovative therapeutic approaches, such as non-invasive brain stimulation techniques (e.g., transcranial magnetic stimulation, transcranial direct current stimulation), target neuroplastic changes in the brain (264). Additionally, combining traditional rehabilitation with novel strategies, such as enriched environments, sensory stimulation, and task-specific training, promotes neuroplasticity and enhances functional recovery. The future direction focuses on optimizing interventions that exploit neuroplasticity mechanisms to facilitate greater and more sustained recovery in stroke survivors.

The future landscape of stroke rehabilitation is intertwined with rapid advancements in assistive technologies aimed at augmenting functional abilities and improving independence. Cutting-edge innovations in robotics, exoskeletons, and wearable devices offer promising avenues to enhance motor recovery and support activities of daily living. Advancements in BCIs aim to seamlessly integrate with the brain’s neural signals, allowing for more intuitive control of assistive devices (265). Moreover, developments in sensor technology and smart home systems enable a more connected and supportive environment for stroke survivors. The future direction underscores the integration of these assistive technologies into rehabilitation programs, aiming to empower stroke survivors, enhance their autonomy, and improve overall quality of life. These future directions herald a paradigm shift in stroke rehabilitation, focusing on individualization, neuroplasticity-driven approaches, and the integration of innovative assistive technologies. Continued research, collaboration, and technological advancements hold substantial promise in revolutionizing stroke rehabilitation practices, ultimately improving outcomes and quality of life for individuals affected by stroke.