Stroke Rehabilitation

Stroke Rehabilitation

Summary

Stroke rehabilitation is a method of treatment that helps stroke patients to relearn basic skills lost after a stroke. Each year, more than 700,000 people in the United States experience a stroke, and two-thirds of those people eventually require rehabilitation, according to the National Institutes of Health.

During a stroke, many patients experience damage to the brain that affects the ability to perform physical and cognitive functions. Rehabilitation helps patients with stroke-related brain damage to learn new ways of performing basic skills such as communicating, dressing, eating and walking. Rehabilitation also can increase a patient’s endurance, flexibility, balance, coordination and strength.

A stroke can have a wide array of effects on a person’s mental and physical abilities. These include:

  • Paralysis or problems controlling movement
  • Sensory disturbances
  • Problems using or understanding language (aphasia)
  • Problems with thinking and memory
  • Emotional problems (e.g., depression)

Following a stroke, several different types of medical professionals may help patients to regain as much of their normal abilities as possible. A patient’s primary physician and other specialist physicians such as neurologists have the leading role in planning a patient’s post-stroke care. Other medical professionals involved in rehabilitation include nurses, physical therapists, occupational therapists, speech pathologists and recreational therapists.

Typically, rehabilitation efforts begin within 24 to 48 hours following a stroke. In this initial period, patients are asked to change positions frequently while in their hospital bed and to perform basic range-of-motion exercises.

Once patients are discharged from the hospital, they will either return home or enter some type of inpatient medical facility depending on the extent of brain damage from the stroke. Patients are likely to undergo stroke rehabilitation for an extended period of time, although the most significant improvements are typically noticed during the first six months of therapy. Patients who successfully complete stroke rehabilitation are urged to make certain lifestyle changes that will reduce their risk of experiencing a second stroke. These include controlling certain diseases that can cause stroke, eating a healthy diet, engaging in regular exercise and not smoking.

About stroke rehabilitation

Stroke rehabilitation is a treatment method that helps patients who have experienced a stroke relearn basic skills lost after the stroke. Rehabilitation helps patients with stroke-related brain damage to learn new ways of performing basic skills such as dressing, eating and walking. Rehabilitation also can increase a patient’s endurance, flexibility, strength and ability to communicate.

Each year, more than 700,000 people in the United States experience a stroke. Two-thirds of these people eventually require rehabilitation, according to the National Institutes of Health (NIH). Stroke is the leading cause of disability in the United States, with more than 4 million Americans currently living with the effects of stroke.

Every stroke is unique and the effect on the patient depends on the location and extent of brain damage, as well as the person’s overall health status before the stroke occurred. People who have a hemorrhagic stroke (which involves bleeding around the brain) are more likely to sustain severe damage than people who have an ischemic stroke (where blood supply to the brain is blocked). According to the NIH:

  • 10 percent of stroke patients recover completely
  • 25 percent recover with minor impairments
  • 40 percent experience moderate to severe impairments
  • 15 percent die shortly after their stroke

Most people who experience a stroke will require some form of rehabilitation therapy. Rehabilitation cannot reverse the brain damage caused by stroke. Unlike some types of cells (e.g., skin cells), brain cells do not regenerate after they have been damaged or killed.

However, the brain can be trained to adapt to cellular damage in ways that allow patients to learn to function by using undamaged nerve cells. Therapy can provide patients with skills that help enhance their quality of life. In some cases, patients may need to relearn old skills. For example, patients who have experienced certain types of stroke-related brain damage may need to relearn how to coordinate their leg movements so they will be able to walk.

In other cases, patients may have to learn new ways of performing tasks that help them overcome damage that occurred during the stroke. For example, patients who have lost the ability to use their left arm may need to learn how to bathe and dress using only their right arm. Patients whose speech has been damaged will need to learn new ways of talking.

Experts believe that rehabilitation is most successful in patients who undertake repetitive practice of their new skills under the guidance of a rehabilitation expert. Other factors that influence the outcome of rehabilitation efforts include the extent of damage to the brain, rapidity of emergency medical treatment, promptness of rehabilitation efforts following the stroke and the skill of the patient’s rehabilitation team. The willingness of family and friends to support the patient during rehabilitation is often a major factor in the long term success of rehabilitation efforts. Most patients make the greatest improvement during the first three to six months of rehabilitation. However, other patients may continue to progress over a long period of rehabilitation time.

Damage that may require stroke rehabilitation

A stroke can have a wide array of effects on a person’s mental and physical abilities. The type of damage that occurs depends on the part of the brain that has been damaged. There are five major types of stroke-related damage:

  • Paralysis or problems controlling movement. Paralysis is among the most common difficulties caused by stroke, and usually affects one side of the body (hemiplegia). In most cases, paralysis occurs on the side of the body that is opposite to the side of the brain that has been damaged. If the damage is confined to weakness rather than paralysis, it is known as hemiparesis. Some patients also may have trouble swallowing (dysphagia) or coordinating movements (ataxia) as a result of damage to the brain.
  • Problems using or understanding language (aphasia). About 25 percent of stroke survivors experience language impairment, according to the National Institutes of Health. This can affect the ability to speak, write, read and understand verbal communication.
  • Sensory disturbances. Some patients experience damage that limits their ability to feel pain, position, temperature or touch. Pain, numbness or other sensations may occur in compromised limbs (paresthesia).
  • Problems with thinking and memory. Strokes can damage portions of the brain used for awareness, learning and memory. This can result in a variety of symptoms ranging from memory loss to an inability to plan or complete complex tasks.
  • Emotional problems. Certain emotions are common in people who have had strokes. These include anger, anxiety, fear, frustration, grief and sadness. Clinical depression is the emotional disorder most often associated with stroke.

People who survive a stroke may have other symptoms related to brain damage. For example, problems with vision are common in people after a stroke. The eyes and brain function together to produce images and stroke can cause blurred vision, eye strain and other vision disturbances. A vision test is recommended after a stroke to assess any stroke-related damage. Additionally, incontinence of the bladder and bowels may occur after a stroke. Exercises for retraining the pelvic muscles may be advised, as well as establishing a regular voiding schedule.

“Learned disuse” is another common problem experienced by stroke survivors. This phenomenon develops when the patient repeatedly attempts to move a limb that has been paralyzed by stroke in the immediate post-recovery period. When this occurs, patients may stop using the limb completely, even though, over time, it may be capable of movement. Rehabilitation specialists use a method called constrained-induced movement therapy, which immobilizes the limb not affected by stroke and forces the patient to relearn to use the affected limb.

People who help with stroke rehabilitation

Following a stroke, several different types of medical professionals may help patients to regain as much normal function as possible. A patient’s primary physician and other specialist physicians have the leading role in planning a patient’s post-stroke care. Physician specialists who may play an essential role in stroke rehabilitation include neurologists and physiatrists (specialists in physical medicine and rehabilitation).

Nurses also play a key role in managing a patient’s stroke rehabilitation. Nurses often are involved in helping patients carry out the basic activities of daily living, such as eating, bathing and toileting. In addition, they may provide guidance in planning a medication schedule and perform other personal care tasks.

Other specialists who may be involved in stroke rehabilitation include:

  • Physical therapist. Helps patients cope with motor and sensory disabilities. These experts may help patients to relearn how to use impaired or paralyzed limbs. They may also suggest exercises that the patient can perform to maintain strength and reduce fatigue.
  • Occupational therapist. Helps patients learn self-directed day-to-day activities. Occupational therapists focus on developing fine motor skills, such as those involved with personal grooming and preparing meals.
  • Speech-language pathologist. Helps patients relearn language techniques or to master new techniques that allow them to circumvent their disabilities. A speech-language pathologist may also be able to help patients relearn how to swallow, an activity that is often impaired following a stroke.
  • Recreational therapist. Helps patients learn thinking and movement skills that will help enhance the quality of leisure time. Recreational therapists may be able to help patients reduce stress and frustration using a variety of recreational activities, such as sports, games and community outings.
  • Visual therapist. Helps patients use various techniques to retrain, strengthen or sharpen visual skills that have been impaired due to damage in certain parts of the brain.
  • Vocational therapist. Helps educate stroke patients about their rights and protections as covered by the Americans with Disabilities Act (ADA). These therapists also help patients with disabilities identify physical and mental strengths and find positions of employment that match those strengths.

In addition, mental health professionals can help patients come to terms with emotional problems that they may be experiencing. Depression is a common symptom among people who have suffered a stroke. Other patients may experience involuntary emotional expression disorder, in which they have difficulty controlling emotional responses. Individual or group counseling may be a valuable component of rehabilitation for both the patient and the patient’s family.

Finally, social workers and case managers may be part of a patient’s care. These people help patients and their family make certain decisions, such as those related to finances or insurance. They may also help coordinate care for the patient. For example, a social worker or case manager may work with the patient’s family to develop plans to return home or enter a long-term care facility. The patient’s local community may also have resources for stroke rehabilitation, such as home delivery of hot meals and volunteer companion visits.

How stroke rehabilitation unfolds

Typically, rehabilitation efforts begin within 24 to 48 hours following a stroke. This usually occurs in an acute-care hospital. Patients are asked to change positions frequently while in bed and to perform basic range-of-motion exercises. These may help stimulate and strengthen limbs damaged by the stroke. Over time, patients may be encouraged to sit up and to move from the bed to a chair. Once patients have begun to walk, they may progress to more complicated tasks, such as bathing, dressing and using a toilet.

Once patients are discharged from the hospital, they either return home or enter a type of inpatient medical facility, depending on the severity of impairment. In general, physicians try to encourage individuals to participate in the most rigorous rehabilitation program that they can handle. This is usually determined by taking into account the patient’s age, degree of disability and overall health.

Patients who are able to return home may attend rehabilitation sessions at an outpatient facility, which is often attached to a larger hospital complex. Patients usually attend these sessions a few times each week for several hours per session. Nursing facilities also may offer outpatient rehabilitation, although such services may be offered for fewer hours than at other outpatient centers.

Home-based rehabilitation is available for many patients, and is especially useful for those without access to transportation or who require treatment from just one type of rehabilitation therapist. Home-based rehabilitation may not be an option for patients who need access to specialized rehabilitation equipment.

Patients with severe impairments may not be able to return home immediately. Instead, they will enter inpatient rehabilitation units, where they may stay for two to three weeks. Therapy sessions may last for three hours and may be scheduled for up to five or six days each week. At the end of this time, patients may be able to return home or they may be admitted to a long-term care facility. About 10 percent of stroke survivors require care in a nursing home or other long-term care facility, according to the National Institutes of Health.

Most patients are involved in rehabilitation programs for several months following their stroke. However, the time required for rehabilitation differs depending on the severity of the patient’s brain damage and which functions are affected. 

Rehabilitation may take many forms, depending on the nature and extent of the patient’s impairments. For example, physical therapists and occupational therapists design repetitive exercise plans for patients, which are aimed to improve the patient’s basic ability to move and function. This many include using a treadmill to help a patient relearn to walk. Physical therapy may also involve helping a patient learn how to use a wheelchair or other assistive device. Physical therapists can assist patients in dealing with fatigue, which is common after stroke. The patient can be taught methods to move more efficiently, conserve energy, and gradually build physical stamina to combat fatigue.

For patients with aphasia or other problems with speech or language, speech therapy may be recommended. During this type of therapy, patients may be given exercises to improve the muscles necessary for speech and swallowing. Patients may also be shown ways to circumvent their speech problems by using alternate forms of communication. 

Therapists may also use a technique called transcutaneous electrical nerve stimulation (TENS) to encourage brain reorganization and regain lost functions. TENS is one of the most common types of electrical therapy and is usually used to treat pain. During the treatment, a small, battery-operated device sends low-voltage electrical current through the skin via electrodes (small, flat rubber adhesive discs). The electricity stimulates the nerves in the affected area and sends signals to the brain that may promote movement.

Lifestyle considerations for stroke rehabilitation

Stroke rehabilitation can help patients to regain some of the physical and mental skills lost as a result of injuries associated with the stroke. However, about 14 percent of stroke survivors will experience a second stroke in the year after the first stroke, according to the U.S. National Institutes of Health.

For this reason, it is important that stroke patients take steps to help prevent future strokes. Factors known to increase the risk for a second stroke include:

  • Diabetes
  • Heart disease
  • High blood pressure (hypertension)
  • High blood cholesterol levels
  • History of transient ischemic attack (TIA)
  • Obesity
  • Older age
  • Sedentary lifestyle
  • Smoking

People with these risk factors are urged to take steps to eliminate one or more if possible. For example, people who are obese can eliminate several risk factors by losing weight through exercising and eating a healthy diet.

Questions for your doctor about rehabilitation

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions and treatments. Patients may wish to ask their doctor the following questions related to stroke rehabilitation:

  1. What kind of stroke rehabilitation do you recommend? Why?
  2. Which of my physical and cognitive impairments may be helped by rehabilitation?
  3. Do I have any impairment that is unlikely to be helped by rehabilitation?
  4. When will my rehabilitation begin?
  5. Who will be involved in supervising my rehabilitation?
  6. Will I require inpatient or outpatient rehabilitation?
  7. How many hours per week will I be in rehabilitation?
  8. How long will my rehabilitation continue?
  9. What are some typical signs that indicate that rehabilitation efforts are working?
  10. What steps can I take to prevent a second stroke?
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