PCPs play pivotal role in poststroke recovery

Strokes happen in an instant, but recovery is slow, unpredictable, and often confusing for patients. Many of the 7 million U.S. stroke survivors face lingering physical deficits, cognitive problems, and mood changes, along with fear of having another stroke. Helping patients navigate that uncertain terrain typically falls to primary care.

“Primary care physicians are often the ones on the ground, helping patients figure out what the care team should look like and how to move forward,” said Elisabeth Breese Marsh, MD, medical director of the Johns Hopkins Bayview Stroke Center in Baltimore. “They help patients figure out which appointments they really need, which rehab to focus on, and what's realistic.”

The central role of primary care physicians (PCPs) in poststroke care was formally recognized in a 2021 American Heart Association/American Stroke Association (AHA/ASA) scientific statement, published in the September 2021 Circulation, and a 2024 stroke rehabilitation guideline by the U.S. Department of Veterans Affairs and Department of Defense (VA/DoD), which was summarized in the February 2025 Annals of Internal Medicine.

“There are enormous opportunities to keep people healthy after stroke, to protect their brains, and prevent dementia and recurrent stroke,” said Walter Kernan, MD, PhD, FACP, emeritus professor of medicine at Yale School of Medicine, in New Haven, Conn., and chair of the writing committee for the AHA/ASA statement. “But they depend on coordinated, aggressive follow-up, starting with a primary care team that sees the big picture.”

Comprehensive care includes identifying and managing common complications, such as cognitive decline, spasticity, and depression, implementing prevention strategies, and coordinating with specialists.

“Most patients return to primary care within a few months of their stroke, often with residual deficits and little ongoing specialty involvement,” said Steven Cramer, MD, a professor of neurology at the University of California, Los Angeles, and author of an Annals of Internal Medicine editorial accompanying the VA/DoD guideline summary. “At that point, the internist becomes the first and last line of defense for stroke-related issues.”

Identifying next steps

Primary care may be the only consistent resource after a stroke, especially in areas without easy access to specialists, said Ramin Zand, MD, MPH, a neurologist at Penn State in Pittsburgh who coauthored a study published in the January 2025 Stroke about physical activity among stroke survivors.

That role starts quickly, he said. Both the AHA/ASA and VA/DoD guidelines recommend patients be seen by primary care within one to three weeks of discharge.

“The early window is critical,” said Dr. Zand. “Stroke survivors often leave the hospital on new medications, with new diagnoses, and no refills beyond 30 days. If no one follows up in time, they run out or fall off track before they've even started.”

Ideally, whoever is caring for the patient during hospitalization, whether a neurologist, internal medicine physician, or family physician, will call the primary care physician and do a warm handoff within a week or two, said Dr. Kernan.

“That early contact ensures blood pressure goals, antiplatelet plans, and other critical steps don't slip,” he said.

Certain complications after a stroke are strikingly common. Weakness, mobility issues, spasticity, fatigue, and cognitive changes can all interfere with recovery and daily life. Yet these problems are sometimes subtle or dismissed by patients who assume they are untreatable.

“Patients often think the stiffness or pain is just their new normal,” said Carolyn Cronin, MD, PhD, chief of the stroke division at Vanderbilt University Medical Center in Nashville, Tenn. “But poststroke spasticity can be treated, and addressing it may significantly improve comfort and function, even if it doesn't restore full mobility.”

With poststroke fatigue, “people come in thinking they might have cancer or another illness because they're so exhausted,” said Dr. Marsh. “But it's often the brain working overtime to recover. If you don't ask, you might never know how much it's affecting their life.”

Cognitive deficits can also be missed, particularly in patients who appear physically intact.

“They tell you they're tired or struggling to return to work, and it turns out they're not processing information the way they used to,” Dr. Marsh said. “That's when simple screening tools can really help.”

Several validated tools can help guide clinical decisions, experts said. For example, motor function can be assessed with the NIH Stroke Scale or Modified Rankin Scale, while brief cognitive screeners like the Montreal Cognitive Assessment (MoCA) or Mini-Mental State Exam offer practical ways to flag cognitive impairment. The AHA/ASA and VA/DoD guidelines offer help with prioritizing rehabilitation strategies and tailoring decision support tools to different stages of recovery.

Depression and anxiety are among the most common, and most underrecognized, consequences of stroke, according to the VA/DoD guideline, with as many as one-third of stroke survivors developing major depression and one-quarter experiencing an anxiety-related disorder within the first year.

Yet many patients don't realize these symptoms are related to their stroke, experts noted, and few receive timely treatment.

“People might say they're fine, but when you ask about sleep, appetite, energy, or irritability, you start to uncover the signs of depression,” said Dr. Marsh. “They're not necessarily sad, but they're disengaged. And that has real consequences for recovery.”

That disengagement can create a ripple effect.

“Depression, anxiety, and motivation loss don't just affect mood—they undermine rehab compliance, sleep, and everything else,” Dr. Cramer said. “There's a real cascading effect. If the emotional health isn't addressed, you can't expect the physical recovery to stick.”

A patient may be socially isolated, unable to work, and physically weaker than before, said Dr. Zand. That leads to depression or anxiety, which in turn undermines their motivation to do the things that will help them recover faster.

Primary care physicians can detect such patterns early by asking focused questions and using structured screening tools like the PHQ-9.

“Even just opening the door—asking patients and families whether things feel different emotionally—can lead to earlier recognition,” Dr. Marsh said.

Despite the wide-ranging needs of stroke survivors, many patients never receive the rehab services that could help, said Dr. Cramer.

“One-third of stroke survivors in the U.S. never see a physical therapist, half never see an occupational therapist, and two-thirds never see a speech therapist,” he said.

In the Annals editorial, Dr. Cramer noted that these gaps often go unnoticed after hospital discharge, highlighting the importance of staying alert to missed opportunities and revisiting referrals, especially when patients present with lingering deficits that could respond to therapy.

“If you catch a whiff of any functional problem, such as trouble walking, speaking, or using their arm, send them,” he said. “It's worth the referral.”

Prioritizing interventions

Even when poststroke needs are clearly identified, few patients are able to pursue every recommended therapy due to inadequate insurance coverage, caregiving resources, or transportation options, among other barriers. Patients may also be grappling with emotional overload and need help prioritizing what's most likely to improve function and prevent long-term decline.

“Often patients are discharged with orders for physical therapy, occupational therapy, and speech therapy, but maybe they only have coverage for 12 visits,” said Dr. Cronin. “If they're mildly impaired across the board, it helps to focus on areas that are likely to have the greatest impact.”

Identify which deficits interfere most with daily life or independence, she advised.

“I might ask a patient, ‘What are you really struggling with right now?’” said Dr. Marsh.

“A frozen shoulder may not seem like a big deal, but if it's affecting sleep and mobility, that may need to take priority over something less disruptive.”

Knowing which patients are likely to benefit from targeted interventions also requires picking up on subtle cues. For example, a patient who says they're just “tired” may actually be showing signs of poststroke depression, or a spouse may mention changes in eating or speech that point to dysphagia—both cues that warrant follow-up.

“Patients with cognitive deficits or communication issues may not advocate for themselves,” Dr. Zand said. “Primary care can step in with referrals and follow up to make sure those services actually happen.”

Gaps in care are especially common during transitions, when patients move from acute rehab to outpatient care or from hospital to home.

“They've just had a stroke, and if they don't have a proactive caregiver or navigator, things can fall apart fast,” Dr. Cronin said. “Sometimes they don't even know who to call.”

Preventing the next stroke

While managing the aftermath is critical, preventing a second stroke is equally urgent.

“There are really two categories of things we do after stroke,” said Dr. Cronin. “One is helping with complications, and the other is preventing another event.”

Risk factor optimization should begin immediately and continue aggressively, especially in the first few months after a stroke when recurrence risk is highest. That means close monitoring of blood pressure, lipid levels, diabetes, and atrial fibrillation, conditions that many patients may not have known they had or that were newly diagnosed during hospitalization.

“If you just control blood pressure, you reduce the chance of a first stroke by up to 80% and the chance of a second stroke by 60%,” said Dr. Zand. “That's how powerful it is. And yet fewer than half of patients nationally have their hypertension under control.”

The AHA/ASA and VA/DoD guidelines recommend intensive medical management of vascular risk factors after stroke. Although they do not specify targets for low-density lipoprotein cholesterol, Dr. Cronin pointed to the Treat Stroke to Target trial, published in the Jan. 2, 2020, New England Journal of Medicine, as supporting the rationale for aggressive lipid lowering. That trial found that achieving a low-density lipoprotein level below 70 mg/dL reduced recurrent cardiovascular events.

Blood pressure should be consistently below 130/80 mm Hg, added Dr. Cronin, noting that patients often believe their blood pressure is controlled even when their readings hover in the 140s.

“Once someone has had a stroke or TIA [transient ischemic attack], they've identified themselves as having a brain at high risk for further injury,” Dr. Kernan said. “That means getting to goal on blood pressure, cholesterol, and diabetes management is all the more important, and should happen as soon as possible.”

Preventing recurrence also means tailoring care to the individual.

“Every stroke survivor is different. Some have carotid disease, others have atrial fibrillation or poorly controlled diabetes,” said Dr. Marsh. “We show them their brain scans, explain what caused their stroke, and then talk through the medications and lifestyle changes they need to prevent another. But long-term, it's the primary care physician who makes sure those goals are met.”

Keeping recovery on track

Although stroke rehabilitation often begins in the hospital or an inpatient rehab unit, it doesn't end there. For many patients, outpatient rehab is critical to regaining function, but follow-through depends on practical support, insurance coverage, and coordinated care.

“It can be overwhelming,” said Dr. Marsh. “You're seeing a stroke specialist, a cardiologist, a rehab doctor, maybe a speech therapist, and then you're trying to manage your medications and go back to work. Primary care can really help patients prioritize, navigate options, and make it all feel doable.”

PCPs should make sure that they're in the loop with rehab and neurology teams and follow up when information isn't readily shared, said Dr. Cronin.

“You want everyone on the same page,” she said. “If a patient has seen cardiology or neurology and you haven't gotten a note, reach out. Otherwise, things get missed, or worse, duplicated or contradicted.”

Coordination is especially vital for patients who don't live near academic stroke centers or who receive care across fragmented systems. “Primary care becomes the constant,” said Dr. Kernan. “They're the only clinician who knows what's going on with the patient from week to week.”

In some cases, PCPs may also be the only clinician available to start treatment, since not every community has a stroke rehab team, Dr. Zand noted. He recommended that primary care teams become familiar with local resources, from home-based rehab and driver modification programs to stroke support groups and assistive technology grants.

“Having a simple list of community supports in the waiting room can make a big difference,” he said. “Sometimes just knowing where to start is enough to keep someone from giving up.”

Dr. Cramer also emphasized the importance of caregiver strain, which is often overlooked.

“Caregivers of stroke patients, especially spouses, have higher rates of depression and even early mortality,” he said. “If they collapse, the whole house of cards falls. PCPs may be the only ones checking in regularly with both patient and caregiver.”

He also urged primary care teams to stay alert for common geriatric risks, such as falls, malnutrition, and social isolation, and approach stroke survivors as a high-risk population.

“Everything you'd worry about in older adults,” he said, “you need to double down on in stroke patients.”