In the United States more than 700,000 people suffer a stroke*
each year, and approximately two-thirds of these individuals survive and
require rehabilitation. The goals of rehabilitation are to help survivors
become as independent as possible and to attain the best possible quality
of life. Even though rehabilitation does not "cure" stroke in that it does
not reverse brain damage, rehabilitation can substantially help people
achieve the best possible long-term outcome.
Rehabilitation helps stroke survivors relearn skills that are lost when
part of the brain is damaged. For example, these skills can include
coordinating leg movements in order to walk or carrying out the steps
involved in any complex activity. Rehabilitation also teaches survivors
new ways of performing tasks to circumvent or compensate for any residual
disabilities. Patients may need to learn how to bathe and dress using only
one hand, or how to communicate effectively when their ability to use
language has been compromised. There is a strong consensus among
rehabilitation experts that the most important element in any
rehabilitation program is carefully directed, well-focused, repetitive
practice - the same kind of practice used by all people when they learn a
new skill, such as playing the piano or pitching a baseball.
Rehabilitative therapy begins in the acute-care hospital after the
patient's medical condition has been stabilized, often within 24 to 48
hours after the stroke. The first steps involve promoting independent
movement because many patients are paralyzed or seriously weakened.
Patients are prompted to change positions frequently while lying in bed
and to engage in passive or active range-of-motion exercises to strengthen
their stroke-impaired limbs. ("Passive" range-of-motion exercises are
those in which the therapist actively helps the patient move a limb
repeatedly, whereas "active" exercises are performed by the patient with
no physical assistance from the therapist.) Patients progress from sitting
up and transferring between the bed and a chair to standing, bearing their
own weight, and walking, with or without assistance. Rehabilitation nurses
and therapists help patients perform progressively more complex and
demanding tasks, such as bathing, dressing, and using a toilet, and they
encourage patients to begin using their stroke-impaired limbs while
engaging in those tasks. Beginning to reacquire the ability to carry out
these basic activities of daily living represents the first stage in a
stroke survivor's return to functional independence.
The types and degrees of disability that follow a stroke
depend upon which area of the brain is damaged. Generally, stroke can
cause five types of disabilities: paralysis or problems controlling
movement; sensory disturbances including pain; problems using or
understanding language; problems with thinking and memory; and emotional
disturbances.
Paralysis or problems controlling movement (motor
control)Paralysis is one of the most common disabilities
resulting from stroke. The paralysis is usually on the side of the body
opposite the side of the brain damaged by stroke, and may affect the face,
an arm, a leg, or the entire side of the body. This one-sided paralysis is
called hemiplegia (one-sided weakness is called
hemiparesis). Stroke patients with hemiparesis or hemiplegia may
have difficulty with everyday activities such as walking or grasping
objects. Some stroke patients have problems with swallowing, called
dysphagia, due to damage to the part of the brain that controls the
muscles for swallowing. Damage to a lower part of the brain, the
cerebellum, can affect the body's ability to coordinate movement, a
disability called ataxia, leading to problems with body posture,
walking, and balance.
Sensory disturbances including painStroke patients may
lose the ability to feel touch, pain, temperature, or position. Sensory
deficits may also hinder the ability to recognize objects that patients
are holding and can even be severe enough to cause loss of recognition of
one's own limb. Some stroke patients experience pain, numbness or odd
sensations of tingling or prickling in paralyzed or weakened limbs, a
condition known as paresthesia.
Stroke survivors frequently have a variety of chronic pain syndromes
resulting from stroke-induced damage to the nervous system (neuropathic
pain). Patients who have a seriously weakened or paralyzed arm commonly
experience moderate to severe pain that radiates outward from the
shoulder. Most often, the pain results from a joint becoming immobilized
due to lack of movement and the tendons and ligaments around the joint
become fixed in one position. This is commonly called a "frozen" joint;
"passive" movement at the joint in a paralyzed limb is essential to
prevent painful "freezing" and to allow easy movement if and when
voluntary motor strength returns. In some stroke patients, pathways for
sensation in the brain are damaged, causing the transmission of false
signals that result in the sensation of pain in a limb or side of the body
that has the sensory deficit. The most common of these pain syndromes is
called "thalamic pain syndrome," which can be difficult to treat even with
medications.
The loss of urinary continence is fairly common immediately after a
stroke and often results from a combination of sensory and motor deficits.
Stroke survivors may lose the ability to sense the need to urinate or the
ability to control muscles of the bladder. Some may lack enough mobility
to reach a toilet in time. Loss of bowel control or constipation may also
occur. Permanent incontinence after a stroke is uncommon. But even a
temporary loss of bowel or bladder control can be emotionally difficult
for stroke survivors.
Problems using or understanding language (aphasia) At
least one-fourth of all stroke survivors experience language impairments,
involving the ability to speak, write, and understand spoken and written
language. A stroke-induced injury to any of the brain's language-control
centers can severely impair verbal communication. Damage to a language
center located on the dominant side of the brain, known as Broca's area,
causes expressive aphasia. People with this type of aphasia have
difficulty conveying their thoughts through words or writing. They lose
the ability to speak the words they are thinking and to put words together
in coherent, grammatically correct sentences. In contrast, damage to a
language center located in a rear portion of the brain, called Wernicke's
area, results in receptive aphasia. People with this condition have
difficulty understanding spoken or written language and often have
incoherent speech. Although they can form grammatically correct sentences,
their utterances are often devoid of meaning. The most severe form of
aphasia, global aphasia, is caused by extensive damage to several
areas involved in language function. People with global aphasia lose
nearly all their linguistic abilities; they can neither understand
language nor use it to convey thought. A less severe form of aphasia,
called anomic or amnesic aphasia, occurs when there is only
a minimal amount of brain damage; its effects are often quite subtle.
People with anomic aphasia may simply selectively forget interrelated
groups of words, such as the names of people or particular kinds of
objects.
Problems with thinking and memoryStroke can cause damage
to parts of the brain responsible for memory, learning, and awareness.
Stroke survivors may have dramatically shortened attention spans or may
experience deficits in short-term memory. Individuals also may lose their
ability to make plans, comprehend meaning, learn new tasks, or engage in
other complex mental activities. Two fairly common deficits resulting from
stroke are anosognosia, an inability to acknowledge the reality of
the physical impairments resulting from stroke, and neglect, the
loss of the ability to respond to objects or sensory stimuli located on
one side of the body, usually the stroke-impaired side. Stroke survivors
who develop apraxia lose their ability to plan the steps involved in a
complex task and to carry the steps out in the proper sequence. Stroke
survivors with apraxia may also have problems following a set of
instructions. Apraxia appears to be caused by a disruption of the subtle
connections that exist between thought and action.
Emotional disturbancesMany people who survive a stroke
feel fear, anxiety, frustration, anger, sadness, and a sense of grief for
their physical and mental losses. These feelings are a natural response to
the psychological trauma of stroke. Some emotional disturbances and
personality changes are caused by the physical effects of brain damage.
Clinical depression, which is a sense of hopelessness that disrupts an
individual's ability to function, appears to be the emotional disorder
most commonly experienced by stroke survivors. Signs of clinical
depression include sleep disturbances, a radical change in eating patterns
that may lead to sudden weight loss or gain, lethargy, social withdrawal,
irritability, fatigue, self-loathing, and suicidal thoughts. Post-stroke
depression can be treated with antidepressant medications and
psychological counseling.
Post-stroke rehabilitation involves physicians; rehabilitation nurses;
physical, occupational, recreational, speech-language, and vocational
therapists; and mental health professionals.
PhysiciansPhysicians have the primary responsibility for
managing and coordinating the long-term care of stroke survivors,
including recommending which rehabilitation programs will best address
individual needs. Physicians are also responsible for caring for the
stroke survivor's general health and providing guidance aimed at
preventing a second stroke, such as controlling high blood pressure or
diabetes and eliminating risk factors such as cigarette smoking, excessive
weight, a high-cholesterol diet, and high alcohol consumption.
Neurologists usually lead acute-care stroke teams and direct patient
care during hospitalization. They sometimes remain in charge of long-term
rehabilitation. However, physicians trained in other specialties often
assume responsibility after the acute stage has passed, including
physiatrists, who specialize in physical medicine and
rehabilitation.
Rehabilitation nursesNurses specializing in rehabilitation
help survivors relearn how to carry out the basic activities of daily
living. They also educate survivors about routine health care, such as how
to follow a medication schedule, how to care for the skin, how to manage
transfers between a bed and a wheelchair, and special needs for people
with diabetes. Rehabilitation nurses also work with survivors to reduce
risk factors that may lead to a second stroke, and provide training for
caregivers.
Nurses are closely involved in helping stroke survivors manage personal
care issues, such as bathing and controlling incontinence. Most stroke
survivors regain their ability to maintain continence, often with the help
of strategies learned during rehabilitation. These strategies include
strengthening pelvic muscles through special exercises and following a
timed voiding schedule. If problems with incontinence continue, nurses can
help caregivers learn to insert and manage catheters and to take special
hygienic measures to prevent other incontinence-related health problems
from developing.
Physical therapistsPhysical therapists specialize in
treating disabilities related to motor and sensory impairments. They are
trained in all aspects of anatomy and physiology related to normal
function, with an emphasis on movement. They assess the stroke survivor's
strength, endurance, range of motion, gait abnormalities, and sensory
deficits to design individualized rehabilitation programs aimed at
regaining control over motor functions.
Physical therapists help survivors regain the use of stroke-impaired
limbs, teach compensatory strategies to reduce the effect of remaining
deficits, and establish ongoing exercise programs to help people retain
their newly learned skills. Disabled people tend to avoid using impaired
limbs, a behavior called learned non-use. However, the repetitive
use of impaired limbs encourages brain plasticity**
and helps reduce disabilities.
Strategies used by physical therapists to encourage the use of impaired
limbs include selective sensory stimulation such as tapping or stroking,
active and passive range-of-motion exercises, and temporary restraint of
healthy limbs while practicing motor tasks. Some physical therapists may
use a new technology, transcutaneous electrical nerve stimulation
(TENS), that encourages brain reorganization and recovery of function.
TENS involves using a small probe that generates an electrical current to
stimulate nerve activity in stroke-impaired limbs.
In general, physical therapy emphasizes practicing isolated movements,
repeatedly changing from one kind of movement to another, and rehearsing
complex movements that require a great deal of coordination and balance,
such as walking up or down stairs or moving safely between obstacles.
People too weak to bear their own weight can still practice repetitive
movements during hydrotherapy (in which water provides sensory stimulation
as well as weight support) or while being partially supported by a
harness. A recent trend in physical therapy emphasizes the effectiveness
of engaging in goal-directed activities, such as playing games, to promote
coordination. Physical therapists frequently employ selective sensory
stimulation to encourage use of impaired limbs and to help survivors with
neglect regain awareness of stimuli on the neglected side of the body.
Occupational and recreational therapistsLike physical
therapists, occupational therapists are concerned with improving motor
abilities. They help survivors relearn motor skills needed for performing
self-directed activities-occupations-such as housecleaning,
gardening, and practicing arts and crafts. Therapists can teach some
survivors how to adapt to driving and provide on-road training. They often
teach people to divide a complex activity into its component parts,
practice each part, and then perform the whole sequence of actions. This
strategy can improve coordination and may help people with apraxia relearn
how to carry out planned actions.
Occupational therapists also teach people how to develop compensatory
strategies and how to change elements of their environment that limit
goal-directed activities. For example, people with the use of only one
hand can substitute Velcro closures for buttons on clothing. Occupational
therapists also help stroke survivors learn how to use assistive devices,
such as canes, walkers, or wheelchairs. Finally, many occupational
therapists teach people how to make changes in their homes to increase
safety, remove barriers, and facilitate physical functioning, such as
installing grab bars in bathrooms.
Recreational therapists help people with a variety of disabilities to
develop and use their leisure time to enhance their health, independence,
and quality of life.
Speech-language pathologistsSpeech-language pathologists
help stroke survivors with aphasia relearn how to use language or develop
alternative means of communication. They also help people improve their
ability to swallow.
Many specialized therapeutic techniques have been developed to assist
people with aphasia. Some forms of short-term therapy can improve
comprehension rapidly. Intensive exercises such as repeating the
therapist's words, practicing following directions, and doing reading or
writing exercises form the cornerstone of language rehabilitation.
Conversational coaching and rehearsal, as well the development of prompts
or cues to help people remember specific words, are sometimes beneficial.
Speech-language pathologists also help stroke survivors develop strategies
for circumventing language disabilities. These strategies can include the
use of symbol boards or sign language. Recent advances in computer
technology have spurred the development of new types of equipment to
enhance communication.
Speech-language pathologists use noninvasive imaging techniques to
study swallowing patterns of stroke survivors and identify the exact
source of their impairment. Difficulties with swallowing have many
possible causes, including a delayed swallowing reflex, an inability to
manipulate food with the tongue, or an inability to detect food remaining
lodged in the cheeks after swallowing. When the cause has been pinpointed,
speech-language pathologists work with the individual to devise strategies
to overcome or minimize the deficit. Sometimes, simply changing body
position and improving posture during eating can bring about improvement.
The texture of foods can be modified to make swallowing easier; for
example, thin liquids, which often cause choking, can be thickened.
Changing eating habits by taking small bites and chewing slowly can also
help alleviate dysphagia.
Vocational therapistsApproximately one-fourth of all
strokes occur in people between the ages of 45 and 65. For most people in
this age group, returning to work is a major concern. Vocational
therapists perform many of the same functions that ordinary career
counselors do. They can help people with residual disabilities identify
vocational strengths and develop resumés that highlight those strengths.
They also can help identify potential employers, assist in specific job
searches, and provide referrals to stroke vocational rehabilitation
agencies.
Most important, vocational therapists educate disabled individuals
about their rights and protections as defined by the Americans with
Disabilities Act of 1990. This law requires employers to make "reasonable
accommodations" for disabled employees. Vocational therapists frequently
act as mediators between employers and employees to negotiate the
provision of reasonable accommodations in the workplace.
Rehabilitation should begin as soon as a stroke patient is stable,
often within 24 to 48 hours after a stroke. This first stage of
rehabilitation usually occurs within an acute-care hospital. At the time
of discharge from the hospital, the stroke patient and family coordinate
with hospital social workers to locate a suitable living arrangement. Many
stroke survivors return home, but some move into some type of medical
facility.
Inpatient rehabilitation unitsInpatient facilities may be
freestanding or part of larger hospital complexes. Patients stay in the
facility, usually for 2 to 3 weeks, and engage in a coordinated, intensive
program of rehabilitation. Such programs often involve at least 3 hours of
active therapy a day, 5 or 6 days a week. Inpatient facilities offer a
comprehensive range of medical services, including full-time physician
supervision and access to the full range of therapists specializing in
post-stroke rehabilitation.
Outpatient unitsOutpatient facilities are often part of a
larger hospital complex and provide access to physicians and the full
range of therapists specializing in stroke rehabilitation. Patients
typically spend several hours, often 3 days each week, at the facility
taking part in coordinated therapy sessions and return home at night.
Comprehensive outpatient facilities frequently offer treatment programs as
intense as those of inpatient facilities, but they also can offer less
demanding regimens, depending on the patient's physical capacity.
Nursing facilitiesRehabilitative services available at
nursing facilities are more variable than are those at inpatient and
outpatient units. Skilled nursing facilities usually place a greater
emphasis on rehabilitation, whereas traditional nursing homes emphasize
residential care. In addition, fewer hours of therapy are offered compared
to outpatient and inpatient rehabilitation units.
Home-based rehabilitation programsHome rehabilitation
allows for great flexibility so that patients can tailor their program of
rehabilitation and follow individual schedules. Stroke survivors may
participate in an intensive level of therapy several hours per week or
follow a less demanding regimen. These arrangements are often best suited
for people who lack transportation or require treatment by only one type
of rehabilitation therapist. Patients dependent on Medicare coverage for
their rehabilitation must meet Medicare's "homebound" requirements to
qualify for such services; at this time lack of transportation is not a
valid reason for home therapy. The major disadvantage of home-based
rehabilitation programs is the lack of specialized equipment. However,
undergoing treatment at home gives people the advantage of practicing
skills and developing compensatory strategies in the context of their own
living environment.
The National Institute of Neurological Disorders and Stroke (NINDS), a
component of the Federal Government's National Institutes of Health (NIH),
has primary responsibility for sponsoring research on disorders of the
brain and nervous system, including the acute phase of stroke and the
restoration of function after stroke. The NINDS also supports research on
ways to enhance repair and regeneration of the central nervous system.
Scientists funded by the NINDS are studying how the brain responds to
experience or adapts to injury by reorganizing its functions (plasticity)
by using noninvasive imaging technologies to map patterns of biological
activity inside the brain. Other NINDS-sponsored scientists are looking at
brain reorganization after stroke and determining whether specific
rehabilitative techniques, such as constraint-induced movement therapy and
transcranial magnetic stimulation, can stimulate brain plasticity, thereby
improving motor function and decreasing disability. Other scientists are
experimenting with implantation of neural stem cells, to see if these
cells may be able to replace the cells that died as a result of a
stroke.
Keeping on Top of Your Condition
Keeping in tune with your disease or condition not only makes treatment less intimidating but also increases its chance of success, and has been shown to lower a patients risk of complications. As well, as an informed patient, you are better able to discuss your condition and treatment options with your physician.
A new service available to patients provides a convenient means of staying informed, and ensures that the information is both reliable and accurate. If you wish to find out more about HealthNewsflash's innovative service, take the tour.
BRAIN
P.O. Box 5801
Bethesda, Maryland 20824
(800)
352-9424
http://www.ninds.nih.gov/
American Heart Association/American Stroke Association
7272
Greenville Avenue
Dallas, Texas 75231-4596
(800) AHA-USA1 (242-8721)
National Stroke Association
9707 East Easter Lane
Englewood,
Colorado 80112-3747
(303)-649-9299
(800) STROKES (787-6537)
http://www.stroke.org/
Stroke Clubs International
805 12th Street
Galveston, Texas
77550
(409) 762-1022
Easter Seals
230 West Monroe Street, Suite 1800
Chicago, Illinois
60606-4802
(312) 726-6200
(800) 221-6827
http://www.easter-seals.org/
National Aphasia Association
29 John Street, Suite 1103
New York,
NY 10038
212-267-2814
http://www.aphasia.org/
American Speech-Language-Hearing Association
10801 Rockville
Pike
Rockville, Maryland 20852-3279
(301) 897-5700
(800)
638-8255
http://www.asha.org/
Agency for Healthcare Research and Quality
P.O. Box 8547
Silver
Spring, Maryland 20907-8547
(800) 358-9295
http://www.ahrq.gov/
National Rehabilitation Information Center
4200 Forbes Boulevard,
Suite 202
Lanham, MD 20706-4829
(301) 562-2400
(800)
346-2742
naricinfo@heitechservices.com
http://www.naric.com/
Caregivers can find useful information by contacting the following
organizations:
Family Caregiver Alliance
690 Market Street
Suite 600
San
Francisco, California 94104
(415) 434-3388
(800) 445-8106 (in
California)
http://www.caregiver.org/
National Family Caregivers Association
10400 Connecticut
Avenue
Suite 500
Kensington, Maryland 20895-3944
(301)
942-6430
(800) 896-3650
http://www.nfcacares.org/
Well Spouse Foundation
63 West Main Street
Freehold, New Jersey
07728
(800) 838-0879
http://www.wellspouse.org/
*A stroke or "brain attack" occurs when brain cells
die because of inadequate blood flow. When blood flow is interrupted,
brain cells are robbed of vital supplies of oxygen and nutrients. About 80
percent of strokes are caused by the blockage of an artery in the neck or
brain; the remainder are caused by a burst blood vessel in the brain that
causes bleeding into or around the brain.
**Functions compromised when a specific region of the
brain is damaged by stroke can sometimes be taken over by other parts of
the brain. This ability to adapt and change is known as plasticity.
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