Stanislaus County Health Services Agency
Coming Back after a Stroke

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 functions.

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 balance.

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 a fall.

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 resistance.

A number of studies show that robot assisted movement can improve upper limb function and coordination after a stroke, but cost and access are a problem.

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 patient.

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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