Post-Stroke Rehabilitation.
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" the effects of 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. Individuals 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 person’s overall condition has been stabilized,
often within 24 to 48 hours after the stroke. The first steps involve promoting
independent movement because many individuals 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.) Depending on many factors—including
the extent of the initial injury—patients may progress from sitting up and
being moved between the bed and a chair to standing, bearing their own weight,
and walking, with or without assistance. Rehabilitation nurses and therapists
help patients who are able to 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
independence.
For some stroke survivors,
rehabilitation will be an ongoing process to maintain and refine skills and
could involve working with specialists for months or years after the stroke.
The types and degrees of disability
that follow a stroke depend upon which area of the brain is damaged and how
much is damaged. It is difficult to compare one individual’s disability to
another, since every stroke can damage slightly different parts and amounts of
the brain. 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 if it involves complete inability to move or hemiparesis
if it is less than total weakness. 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 pain
Stroke patients may lose the ability
to feel touch, pain, temperature, or position. Sensory deficits also may 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 symptom known as paresthesias.
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 bladder muscles. Some may lack
enough mobility to reach a toilet in time. Loss of bowel control or
constipation also may 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.
Stroke survivors frequently have a
variety of chronic pain syndromes resulting from stroke-induced damage to the
nervous system (neuropathic pain). 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" (caused by a stroke to the thalamus, which
processes sensory information from the body to the brain), which can be
difficult to treat even with medications. Finally, some pain that occurs after
stroke is not due to nervous system damage, but rather to mechanical problems
caused by the weakness from the stroke. 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 lack of movement
in a joint that has been immobilized for a prolonged period of time (such as
having your arm or shoulder in a cast for weeks) and the tendons and ligaments
around the joint become fixed in one position. This is commonly called a
"frozen" joint; "passive" movement (the joint is gently
moved or flexed by a therapist or caregiver rather than by the individual) 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.
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. The dominant centers for language are in the left side of the
brain for right-handed individuals and many left-handers as well. 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 of the brain involved in
language function. People with global aphasia lose nearly all their linguistic
abilities; they cannot understand language or use it to convey thought.
Problems
with thinking and memory
Stroke 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 the stroke-impaired side. Stroke survivors who
develop apraxia (loss of ability to carry out a learned purposeful
movement) cannot plan the steps involved in a complex task and act on them in
the proper sequence. Stroke survivors with apraxia also may 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
disturbances
Many 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.
Additional complications that may
follow a stroke, some of which may be able to be treated, include:
- visual problems
- problems sleeping
- sexual dysfunction
- seizures
- fatigue
Post-stroke rehabilitation involves
physicians; rehabilitation nurses; physical, occupational, recreational,
speech-language, and vocational therapists; and mental health professionals.
Physicians
Physicians 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 also are 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
participate on the long-term rehabilitation team. Other subspecialists often
lead the rehabilitation stage of care, especially physiatrists, who
specialize in physical medicine and rehabilitation.
Rehabilitation
nurses
Nurses 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 move out
of a bed and into 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
therapists
Physical 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.
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 therapists
Like physical therapists,
occupational therapists are concerned with improving motor and sensory
abilities, and ensuring patient safety in the post-stroke period. They help
survivors relearn skills needed for performing self-directed activities (also
called occupations) such as personal grooming, preparing meals, and
housecleaning. 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 change elements of their
environment that limit activities of daily living. For example, people with the
use of only one hand can substitute hook and loop fasteners (such as Velcro)
for buttons on clothing. Occupational therapists also help people 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
pathologists
Speech-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,
and they work with patients to develop problem-solving and social skills needed
to cope with the after-effects of a stroke.
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 as 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
special types of 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
therapists
Approximately 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
résumés 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, sometimes within 24 to 48 hours after a stroke.
This first stage of rehabilitation can occur within an acute-care hospital;
however, it is very dependent on the unique circumstances of the individual
patient.
Recently, in the largest stroke
rehabilitation study in the United States, researchers compared two common
techniques to help stroke patients improve their walking. Both
methods—training on a body-weight supported treadmill or working on strength
and balance exercises at home with a physical therapist—resulted in equal
improvements in the individual’s ability to walk by the end of one year. Researchers
found that functional improvements could be seen as late as one year after the
stroke, which goes against the conventional wisdom that most recovery is
complete by 6 months. The trial showed that 52 percent of the participants made
significant improvements in walking, everyday function and quality of life,
regardless of how severe their impairment was, or whether they started the
training at 2 or 6 months after the stroke.
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 units
Inpatient 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
units
Outpatient 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
facilities
Rehabilitative 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 programs
Home 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 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. In the recent stroke rehabilitation trial, intensive balance and
strength rehabilitation in the home was equivalent to treadmill training at a
rehabilitation facility in improving walking.
The National Institute of
Neurological Disorders and Stroke (NINDS), a component of the U.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 NIH’s Eunice Kennedy
Shriver National Institute of Child Health and Human Development, through
its National Center for Medical Rehabilitation Research, funds work on
mechanisms of restoration and repair after stroke, as well as development of
new approaches to rehabilitation and evaluation of outcomes. Most of the
NIH-funded work on diagnosis and treatment of dysphagia is through the National
Institute on Deafness and Other Communication Disorders. The National
Institute of Biomedical Imaging and Bioengineering collaborates with NINDS and
NICHD in developing new instrumentation for stroke treatment and
rehabilitation. The National Eye Institute funds work directed at
restoration of vision and rehabilitation for individuals with impaired or low
vision that may be due to vascular disease or stroke.
The NINDS 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)—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.
For more information on neurological
disorders or research programs funded by the National Institute of Neurological
Disorders and Stroke, contact the Institute's Brain Resources and Information
Network (BRAIN).
Source: NIH USA
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