Rehabilitation:

Most people who survive a stroke have some type of disability. But many people are able to make significant improvements through rehabilitation. According to the National Stroke Association:

• 10% of stroke survivors recover almost completely
• 25% recover with minor impairments
• 40% experience moderate-to-severe impairments that require special care
• 10% require care in a nursing home or other long-term facility

For the best chance of improvement and regaining abilities, it is important that rehabilitation starts as soon as possible after a stroke. Rehabilitation therapy is started in the hospital as soon as a patient� ' s condition has stabilized. Initial range of motion exercises involve a nurse or physical therapist moving a patient� ' s affected limb (passive exercise) and having the patient practice moving the limb (active exercise). Patients are encouraged to gradually sit, stand, and walk and then to perform tasks of daily living (bathing, dressing, using the toilet).

Some patients will experience the fastest recovery and regain functional abilities in the first few days, while others will continue to show improvement during the first 6 months or longer. Recovery is an ongoing process and with good rehabilitation providers and family support, patients can continue to make progress.

Rehabilitation Services

Once a patient has been discharged from the hospital, rehabilitation continues at home or in an outpatient program. Some patients may be transferred to a rehabilitation hospital before going home. Others may require care in a long-term or skilled nursing facility. In addition to the ongoing care of a primary care physician or neurologist, a rehabilitation team may include:

• Physical therapists who focus on restoring physical function and helping patients improve strength, balance, and coordination
• Occupational therapists to help patients regain ability to perform activities of daily living
• Speech-language therapists to help improve language skills
• Psychologists to help with the patient� ' s mental and emotional state
• Social workers to help patients and families with financial arrangements and coordinating home services

Effects of Stroke

A stroke can cause various disabilities. The type of disability depends on which part of the brain was damaged. According to the U.S. National Institutes of Health, the five main types of stroke disabilities are:

• Paralysis or Problems Controlling Movement (Motor Control). Paralysis tends to occur on opposite side of the body from the side of the brain damage. If someone has brain damage on the left side of the brain, the right side of the body will be affected, and the reverse is also true. One-sided paralysis is called hemiplegia, and one-sided weakness is called hemiparesis. Hemiplegia or hemiparesis can affect a person� ' s ability to walk or grasp objects. Loss of muscle control can also cause problems swallowing (dysphagia) or speaking (dysarthria). Patients may also have difficulty with coordination and balance (ataxia).
• Sensory Disturbances Including Pain. Stroke can affect the ability to feel touch, pain, temperature, or position. Pain, numbness, and tingling or pricking sensations can occur in the paralyzed or weakened limb (paresthesia). Sometimes patients have problems recognizing their affected arm or leg. Some stroke survivors experience chronic pain, which often results from a joint becoming immobilized or “frozen”. Muscle stiffness or spasms are common. Sensory disturbances can also affect the ability to urinate or control bowels.
• Problems Using or Understanding Language (Aphasia). At least 25% of stroke survivors have language impairments, which affect the ability to speak, write, and understand spoken or written language. This condition is called aphasia. Sometimes patients will know the right words but have problems saying them (dysarthria).
• Problems with Thinking and Memory. Stroke can affect attention span and short-term memory. This can impair the ability to make plans, learn new tasks, follow instructions, or comprehend meaning. Some stroke survivors are unable to recognize or understand their physical impairments or are unaware of sensations affecting the stroke-impaired side of the body.
• Emotional Disturbances. Some emotional and personality changes that follow a stroke are caused by the effects of brain damage. Clinical depression is very common, and is not only a psychological response to stroke but a symptom of physical changes in the brain. Patients may have difficulty controlling emotions or may exhibit inappropriate emotional responses (crying, laughing, or smiling for no apparent reason).

Rehabilitation Programs

Because stroke affects different parts of the brain, specific approaches to managing rehabilitation vary widely among individual patients:

• Exercise program. Recent guidelines from the Veteran� ' s Administration recommend that patients get back on their feet as soon as possible to prevent deep vein thrombosis. Patients should try to walk at least 50 feet a day. Assisted devices or bracing are sometimes used to help support the legs. Treadmill exercises can be very helpful for patients with mild-to-moderate dysfunction. Exercise should be tailored to the stroke survivor's physical condition and can include aerobic, strength, flexibility, and neuromuscular (coordination and balance) activities.
• Retraining muscles. Stretching and range-of-motion exercises are used to help treat spastic muscles. They can also help patients regain function in a paralyzed arm. Multiple techniques have been developed and studied.
• Speech therapy and sign language. Intense speech therapy after a stroke is important for recovery. Some doctors recommend 9 hours a week of therapy for 3 months. Language skills improve the most when family and friends help reinforce the speech therapy lessons.
• Swallowing training. Training patients and their caregivers regarding swallowing techniques, as well as safe and not safe foods and liquids, is essential for preventing aspiration (accidental sucking in of food or fluids into the airway).
• Attention training. Problems with attention are very common after strokes. Direct retraining teaches patients to perform specific tasks using repetitive drills in response to certain stimuli. (For example, they are told to press a buzzer each time they hear a specific number.) A variant of this approach trains patients to relearn real-life skills, such as driving, carrying on a conversation, or other daily tasks.
• Occupational training. Occupational therapy is important and improves daily living activities and social participation.

Drug Therapy for Rehabilitation

Medication can sometimes help relieve specific effects of stroke:

• Dantrolene (Dantrium), tizanidine (Zanaflex), and baclofen (Lioresel) are used to treat spasticity.
• Heparin, a blood-thinning drug, is used to prevent blood clots from forming in the veins of the legs (thrombosis).
• Some patients experience constant hiccups, which can be very serious. Chlorpromazine and baclofen are among the drugs used for this condition.
• Antidepressants may be prescribed for treatment of depression.

Managing the Emotional Consequences

A stroke is emotionally challenging both for patients and their families. The caregiver's emotions and responses to the patient are critical. Patients do worse when caregivers are depressed, overprotective, or not knowledgeable about the stroke. They do best when caregivers and family are encouraging and supportive. Everyone benefits when patients are able to function as independently as possible to the best of their abilities.