Stroke, as the name implies, can happen swiftly, with little or no warning.
In a matter of minutes an active, fully engaged adult is transformed into
a patient who may no longer have full control of movement, speech or bodily
An estimated 600,000 Americans suffer a stroke every year. More than
a quarter die as a result. But the majority enter a new reality where
survival means relearning how to do the simple things that were once taken
for granted. Once the initial crisis has passed, stroke rehabilitation
is the key element in recovering lost skills.
A stroke occurs when the blood supply to an area of the brain is interrupted.
In an ischemic stroke, the most common kind, this happens because of a
clot in a blood vessel. In a hemorrhagic stroke it happens because of
a ruptured blood vessel that causes bleeding in the brain.
Strokes and the damage they do vary enormously depending on the specific
area of the brain that’s affected and the extent of the damage.
A stroke can happen in any area of the brain and will affect whatever
part of the body that the specific area of the brain controls.
Common stroke damage includes paralysis of a limb or one side of the
body, loss of speech, vision problems, difficulties with thinking and
memory, difficulty swallowing, loss of bladder control and problems with
Physical rehabilitation focuses on getting the patient mobile and improving
coordination, strength and endurance. Up to 80 percent of patients are
unable to walk independently right after a stroke, but due to a combination
of physical rehabilitation and natural recovery that number later drops
to less than 20 percent.
Because walking requires automatic rhythmic movement the healthy leg
helps integrate the coordination of the healthy and impaired legs. A patient
might need to use a walker or cane in the early stages and gradually progress
to more independent walking.
Some rehab units have had good results using a harness that supports
a patient on a treadmill, giving the patient as much support and balance
as he needs learning to walk again.
Regaining Arm and Hand Agility
A stroke often affects one side of the body and in the past there was
a tendency to focus on compensating for loss of function in the arm and
hand by favoring the arm that wasn’t affected. Unlike the legs,
where coordination is necessary for walking, hands can be used independently.
When a limb is not used over an extended period, a learned disuse develops.
Loss of the use of an arm is the main factor in functional disability
after a stroke. Studies show that intensive repetition of movements can
reprogram the brain, reestablishing lost connections in damaged areas.
A number of research efforts are currently underway to develop relearning
techniques that will encourage this type of neurological reorganization.
One approach being tried at a number of rehabilitation facilities is
Constraint-Induced Movement (CIM). With CIM patients wear a large mitt
or sling on their good arm all day for two weeks. During that period they
perform a series of tasks requiring use of the impaired arm and hand,
without help from their immobilized limb. Tasks include stacking blocks,
flipping over cards or checkers, screwing a nut onto a bolt, picking up
and releasing marbles and measuring beans using small cups. As the patient
progresses, tasks requiring increasing strength, dexterity or fine motor
skills can be added.
Berlin researchers using CIM found that after therapy the amount of use
patients were able to make of the affected arm doubled.
A national clinical trial, EXCITE (Extremity Constraint Induced Therapy
Evaluation) to further investigate this technique is currently underway
at seven locations around the United States.
The therapy requires that patients have at least some use of the hand
and be motivated, since a great deal of precise and intense training is
involved. Older patients with balance problems need to be carefully evaluated
to ensure that constraining their good arm does not put them at risk of
Although promising, CIM is expensive, requiring many hours of patient/therapist
contact and supervision. Some facilities are experimenting with less costly
versions of the therapy, involving one individualized therapy session
and another group session. The patient then works independently at home
in two hour blocks for 12 to 24 sessions.
Another approach to retraining of arms and hands uses a computer supported
robotic device. Spaulding Rehabilitation Hospital in Boston uses MANUS,
a robotic arm that gives the patient’s arm as much support as she
needs to accomplish a specific task such as aiming at a computer-generated
target. As the patient’s strength increases, the robot can provide
A number of studies show that robot assisted movement can improve upper
limb function and coordination after a stroke, but cost and access are
Stroke is the leading cause of disability in the United States. The majority
of patients will have significant improvement up to a year following a
stroke. Some of that improvement will come about as a result of natural
healing, but much of it is related to the efforts of therapists and the
Stroke patients and their caregivers should take advantage of any opportunities
available to them for therapy, not just during the initial hospital stay
but after returning home. Physical and occupational therapists are trained
to evaluate the patient’s physical capabilities and potential and
ways the home and workplace can be modified to meet new needs. As well
as working one on one with patients, therapists can suggest exercises
to enhance mobility, strength, balance and fine motor control that can
be performed successfully at home or at work.
Although repetition may be tedious, the brain is capable of learning
at any age. Research shows that intense repetition and practice can lay
down new pathways in the brain, taking over for areas damaged by the stroke.
Even small gains for stroke patients can make an enormous difference in
independence and ability to carry out the tasks of daily living.
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