Stroke: Managing Patient Recovery

Copyright © 2010 Wild Iris Medical Education, Inc. All Rights Reserved.

By Michael Jay Katz, MD, PhD

Michael Jay Katz has taught anatomy, physical diagnosis, and scientific writing in

the medical school of Case Western Reserve University for more than twenty-five

years. He has written sixteen books and eighty papers and essays. He is

currently the anatomy and physiology consultant for Taber's Cyclopedic Medical

Dictionary.

COURSE OBJECTIVE:  The purpose of this course is to present the primary elements of post-hospital care recovering stroke patients.

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

List the primary-care goals for a recovering stroke patient Describe the basic features of medical rehabilitation programs for stroke patients Summarize the lifestyle changes recommended to reduce the recurrence of stroke Discuss the process of physical rehabilitation of stroke patients

MOVING INTO THE RECOVERY PHASE

Acute care for a stroke takes place over the course of days, but recovery and

rehabilitation takes place over the course of months and years.

Discharge from the Hospital

In the United States, the average hospital stay for an acute stroke patient was

4.9 days in 2006 (CDC, 2010b). From the hospital, 30% of stroke patients were

discharged home with no planned home health care, 17% were discharged

home with planned home health care, 20% were discharged to a rehabilitation

center, and 33% were sent to a skilled nursing facility (Kind et al., 2010).

Patient Education

As the hospital stroke team turns a stroke patient over to the rehabilitation team,

the patient, family, and caregivers need to be informed, educated, and “kept in

the loop.” After the hospitalization, these people will be making the day-to-day

healthcare decisions, and these decisions need to be based on accurate, realistic

information. For example, post-stroke patients need to understand their

medications; they need to know:

Why they are taking an antiplatelet drug How the drug works What specific dangers the drug poses The addition of which other drugs will worsen the risk of bleeding That antiplatelet therapy will continue for their entire lifetime

Patient education will already have begun during a patient’s hospitalization,

with stroke nurses explaining the causes for the patient’s symptoms and the

reasoning behind the treatments (Summers et al., 2009). Yet the sudden influx

of medical information at discharge can be overwhelming. Therefore, patients

and families should be given instructions and guidelines in the form of printed

materials that can be reviewed at home. Nurses should also include a list of

medically accurate stroke websites; the “Resources” section at the end of this

course offers some suggestions.

THE ROLE OF NURSES IN THE DISCHARGE PROCESS

Nurses are the key players in organizing a patient’s discharge from the hospital.

Nurses are with the patient throughout the day, and they have seen the full

range of the patient’s limitations and dependencies. While a patient is still in the

hospital, nurses on the stroke team initiate the patient’s transition into the

appropriate supervised rehabilitation programs. As the time of discharge

approaches, nurses arrange to have a patient’s limitations assessed formally by

specialists—physiotherapists, occupational therapists, speech therapists,

psychologists, and nutritionists. These professionals then make

recommendations that can be taken into account before physicians have begun

discharging the patient.

Nurses are also the family educators. Nurses explain the pathology of the

patient’s particular stroke, they describe practical problems that the patient will

face, and they outline the methods for preventing a recurrence of the stroke. A

nurse will demonstrate how to manage continuing healthcare problems, such as

changing dressings and applying topical medicines. A nurse will give advice to

caregivers and family about communicating with a patient who is aphasic or

who has significant motor or sensory deficits. A nurse should also check to see

that follow-up visits with a physician are scheduled and that the family and

patient are aware of these appointments.

In their discussions with the patient and family, a nurse should explain that

almost 3/4 of stroke survivors will eventually need their family’s assistance at

home and that the practicalities and costs of that home help should be thought

through in advance. Finally, a nurse should make sure that a social worker or

community liaison provides referrals to government and nonprofit help

agencies, support groups, and other helpful community resources (Summers et

al., 2009).

Two Major Goals of the Recovery Process

Discharge from the hospital is the beginning of what is often an arduous

process. After a stroke, patients can be limited in their ability to interact with

the world or in their ability to independently carry out their wishes. For

example, they may be unable to speak clearly, or they may be unable to move

one of their limbs. Recovering lost skills through physical rehabilitation is one

major goal of post-hospital recovery.

There is a great deal of variability in how fast and to what extent people recover

after a stroke. There are, however, some general time lines of recovery. After a

stroke, patients reach their maximum ability to perform activities of daily living

more slowly when their stroke has left them severely disabled. Mildly disabled

stroke patients tend to reach their best level of functioning 2-1/2 months after

the stroke. Moderately disabled stroke patients reach their peak in about 3

months. However, severely disabled stroke patients may still be improving 5

months after the stroke (Stein, 2008).

Patients take longer to recover from more disabling strokes, and their progress

is slow. Because some skills return very slowly while other abilities are never

regained, post-stroke physical rehabilitation tries to help patients get on with

their lives by learning substitute skills as well as by working on regaining lost

skills.

As they restrengthen their minds and bodies and learn new adaptations, stroke

patients are medically vulnerable. One-fifth of the men and 1/4 of the women

who have had their first stroke will die within the year, and 1/4 of stroke

survivors will have another stroke within 5 years (University Hospital, n.d.).

Therefore, after discharge from the hospital, patients need to embrace lifestyle

and medical regimens that reduce the risk of further strokes. Prevention of

additional strokes through medical rehabilitation is a second major goal of

post-hospital recovery.

COMPREHENSIVE DISEASE MANAGEMENT PROGRAMS

Coordinating the various medical and lifestyle regimens that are needed to

reduce the risk of another stroke can be a complex task. As an aid, medical

rehabilitation can be more efficiently organized using a comprehensive disease

management program that will ensure thorough medical care after a patient’s

discharge (Furie et al., 2009).

One good example is the PROTECT program, which is designed for ischemic

stroke patients and was developed at the UCLA Medical Center. This program

begins its post-hospital care planning while the patient is still in the hospital.

PROTECT uses only existing resources and personnel to create an

individualized regimen of medications (antithrombotics, ACE-inhibitors,

thiazide diuretics, and statins), exercise, diet, education, and regular check-ups

that continue for a year.

The PROTECT program is designed to be easy to implement. Its website offers

information and printable forms, including a preprinted admission order sheet, a

medication algorithm, a patient tracking form, interdisciplinary sheets, patient

information sheets (in English and Spanish), the draft of a letter to the primary

care physician and a discharge summary template (PROTECT, 2002).

MEDICAL REHABILITATION GOALS AND PLANS

After a stroke, the patient’s health is unstable, and they are at risk for

cardiovascular problems and for additional strokes. Medically, the post-hospital

goals for a stroke patient are to avoid or to quickly deal with medical

complications and to prevent the recurrence of strokes. Plans to safeguard a

patient’s health can be called medical rehabilitation. A number of medical

conditions need to be addressed in a medical rehabilitation program.

Treating the Prothrombotic State

Patients with ischemic strokes are assumed to have underlying prothrombotic

conditions. For ischemic strokes not due to emboli originating in the heart, daily

aspirin, aspirin plus dipyridamole, or aspirin plus clopidogrel are usually

prescribed (Furie et al., 2009). For cardioembolic ischemic strokes (e.g., from

atrial fibrillation), warfarin (Coumadin) is the more effective antithrombotic

medication (Manning & Hart, 2009). (Without a specific medical reason,

aspirin must not be added to warfarin therapy.) New evidence suggests that, in

the future, strokes from atrial fibrillation may be more safely prevented by

different antithrombotic drugs, such as vitamin K-antagonists or dabigatron, or

by new techniques for suppressing the arrhythmia (McArthur & Lees, 2010).

Treating Hypertension

High blood pressure puts a stroke victim at risk for additional strokes; therefore,

reducing hypertension is a generally accepted post-stroke goal. One common

guideline suggests gradually reducing the blood pressure of a post-stroke

patient over several months, with an end goal of <130/80 mm Hg. A diuretic or

a diuretic plus an ACE inhibitor are usually the recommended medications.

This blood pressure goal comes with caveats:

After a stroke, the normal autoregulation of cerebral blood flow may not be working efficiently, and lowering blood pressure may produce hypotensive or even ischemic symptoms.

Aggressive (stringent) blood pressure treatment appears to increase mortality in patients >80 years of age.

Antihypertensive drugs should be chosen individually to best match the patient and their other health problems.

Lifestyle changes (e.g., improved diet, weight loss, and increased exercise) are an integral part of a medical antihypertensive program (Furie et al., 2009).

Treating Diabetes and Reducing Excess Body Weight

Diabetes doubles a person’s risk for having an ischemic stroke. Maintaining

good glycemic control, with HbA1c levels <7%, will reduce the microvascular

(e.g., retinal and kidney) complications of diabetes. By itself, good glycemic

control has not been shown to have a large effect on reducing a diabetic

patient’s risk for stroke; nonetheless, good glycemic control is recommended

for all diabetic stroke patients.

Overweight patients also have an increased risk of stroke. “As with glycemic

control, there are no data to confirm that weight reduction will reduce the risk

of recurrent stroke. However, weight reduction is potentially beneficial for

improved control of other important parameters, including blood pressure,

blood glucose, and serum lipid levels” (Furie et al., 2009). The recommendation

is that patients maintain a body mass index (BMI) between 18.5 and 24.9 kg/m2

and a waist circumference of <102 cm (40 in) for men and <88 cm (35 in) for

women.

For both diabetes and excess body weight, lifestyle changes (e.g., improved diet

and increased exercise) are key parts of the medical rehabilitation program.

Treating Dyslipidemia

Dyslipidemia is abnormal amounts of lipids and lipoproteins in the blood. High

levels of low-density lipoprotein cholesterol (LDL cholesterol), low levels of

high-density lipoprotein cholesterol (HDL cholesterol), and a high ratio of total

cholesterol to HDL cholesterol each put a person at risk for developing

atherosclerosis of the carotid artery. Evidence is unclear, however, as to

whether there is a direct relationship between specific dyslipidemias and stroke

risk.

Nonetheless, drug therapy with statins does reduce a person’s risk of having

an ischemic stroke. This effect is thought to be mainly a function of a statin’s

antiatherothrombotic actions rather than its cholesterol-lowering actions.

Current recommendations include:

For ischemic stroke patients with coronary artery disease, a statin is used to reach the blood lipid goal of LDL cholesterol <100 mg/dl; for especially high-risk patients, the goal is LDL cholesterol <70 mg/dl.

For ischemic stroke patients without known coronary artery disease, 80 mg atorvastatin should be taken daily.

For ischemic stroke patients with HDL cholesterol <40 mg/dl, consider adding niacin or gemfibrozil to the statin.

Lifestyle changes (e.g., improved diet, weight reduction, and increased exercise) are key to an effective dyslipidemia correction program (Furie et al., 2009).

Treating Depression

Clinical depression is common after stroke; in fact, it has been estimated that as

many as 40% of patients suffer treatable depression (Stein, 2008). Patients at

high risk for clinical depression or anxiety can be identified within the first 2

weeks after a stroke with the brief and easy-to-use Hospital Anxiety and

Depression Scale (Sagen et al., 2010, 2009). Other brief depression assessment

tools have also proven useful (Pfeil et al., 2009; Roger & Johnson-Greene,

2009; Lee et al., 2008). Post-stroke depression is usually treated with selective

serotonin reuptake inhibitors, such as fluoxetine, paroxetine, or sertraline.

Treating Other Common Medical Problems

After a stroke, it is not unusual for patients to develop other medical problems.

The following table shows some of these problems and the medications used to

treat them.

COMMONLY USED MEDICATIONS

Problem Medication

Source: Stein, 2008.

Bladder instability Anticholinergics (e.g., oxybutynin or tolterodine)

COMMONLY USED MEDICATIONS

Problem Medication

Erectile dysfunction Phosphodiesterase type 5 inhibitors (sildenafil, vardenafil)

Impaired mental arousal

Stimulants (dextroamphetamine, methylphenidate)

Muscle spasticityAntispasmodics (e.g., baclofen, dantrolene, diazepam, tizanidine)

Pain syndromes Anticonvulsants (carbamazepine, gabapentine)

Seizure disorders Anticonvulsants (carbamazepine, gabapentine)

Additional Medical Procedures

Certain stroke patients may benefit from additional medical procedures. Carotid

endarterectomy is often recommended for ischemic stroke patients with

ipsilateral carotid artery stenosis >70%. Endarterectomy is also appropriate in

some patients with ipsilateral stenosis between 50% and 70%. Carotid stenting

is used as an alternative to endarterectomy in some medical centers (Stein,

2008; Summers et al., 2009).

Patients who had a subarachnoid hemorrhage (SAH) and subsequent aneurysm

clipping or coil placement have a risk of recurrent bleeding. The most

vulnerable patients are those who are elderly, who smoke, who are

hypertensive, or who had large or multiple aneurysms. For SAH patients who

were treated surgically or endovascularly, it is suggested that the status of their

obliterated aneurysm be checked with imaging at 3 and 6 months after the

procedure (Singer et al., 2009).

Residual movement problems, such as joint contractures, can sometimes be

improved surgically, although rigorous physical therapy is usually the most

successful way to regain strength and control of muscles. Typically,

spontaneous recovery of motor abilities occurs in the first 6–8 weeks, and

physical rehabilitation can continue the progress. By 6–9 months, most patients

have reached the peak of their recovery. Any surgical intervention is usually

held until >6 months after the stroke, at which time a realistic picture of the

patient’s permanent limitations becomes clearer (Sawyer, 2007).

LIFESTYLE MODIFICATIONS

Medical rehabilitation is most effective when patients make therapeutic changes

in their daily lives. Smokers should quit, heavy people should lose weight,

sedentary people should exercise, and high-fat, high-calorie diets should be

replaced with low-fat high-fiber diets. Each of these lifestyle modifications can

slow the progression of atherosclerosis and help to maintain lower blood

pressures

These principles—stop smoking, eat a healthy diet, exercise, and stay thin—

will be familiar to most patients. It is the job of the medical rehabilitation team

to work with the patient to give specificity to these familiar general statements.

The medical team needs to offer practical advice that the patient can follow and

that the patient believes is worth following.

Stop Smoking

Therapeutic lifestyle changes begin with smoking cessation. Carbon monoxide

and other poisons in cigarette smoke damage cells throughout the body, and

cigarette smoking increases the risk of all forms of stroke: the more a person

smokes, the higher the risk. Therefore, stroke patients who smoke are strongly

urged to stop smoking (Furie et al., 2009).

Many people find it difficult to stop smoking. A nurse or other member of the

stroke team can begin by telling a patient that continued smoking increases their

risk of recurrent stroke, serious heart problems, and death, while stopping

smoking reduces these risks.

THE 5 A’s FOR SMOKERS

Health counselors are encouraged to use the five A’s with their patients who

smoke:

Ask. Ask the patient if they smoke. Advise. Strongly advise quitting. Assess. Ask the patient whether they are ready to quit. Assist. Help to formulate a workable smoking cessation plan, including medications

and regular interactions with a counselor. Arrange. Take steps to put the plan into action: organize the necessary medications,

counseling, and follow-up visits.

Eat a Low-Fat/High-Fiber Diet

The American Dietetic Association has collected evidence demonstrating that a

low-fat diet with 12 g to 33 g per day of fiber from whole foods or up to 42.5 g

per day from supplements can help to reduce blood pressure, correct

dyslipidemia, reduce indicators of chronic inflammation, and reduce weight

(Am. Diet. Assoc., 2008). A low-fat/high-fiber diet has also been shown to

reduce the risk of developing coronary artery disease.

In one large study of elderly people (Mozaffarian et al., 2003), eating whole-

grain fiber in the equivalent of an extra two slices of whole-grain bread per day

reduced the number of:

Nonfatal myocardial infarctions by 6% Deaths from coronary artery disease by 13% Ischemic strokes by 24%

Dietary counseling programs can help to maintain long-term improvements in a

patient’s eating habits. A dietary counseling program begins with a dietary

history and measures the patient’s height, weight, and waist circumference.

Patients (or their families) are then given diaries in which to record their

complete food and drink intake for five days. At follow-up visits, the patient’s

height, weight, and waist circumference are measured, the patient’s progress is

charted, and specific dietary recommendations are suggested. The diet

rehabilitation program should continue until the patient has found a stable,

healthy eating routine.

Lose Weight

Overweight ischemic stroke patients should be encouraged to lose weight. The

recommended goal is to maintain a body mass index (BMI) between 18.5 and

24.9 kg/m2 and a waist circumference for men <102 cm (40 in) and for women

<88 cm (35 in).

BODY MASS INDEX

  21 22 23 24 25 26 27 28 29 30 31

Source: NHLBI, 2008.

4'10" 100 105 110 115 119 124 129 134 138 143 148

5'0" 107 112 118 123 128 133 138 143 148 153 158

5'1" 111 116 122 127 132 137 143 148 153 158 164

5'3" 118 124 130 135 141 146 152 158 163 169 175

5'5" 126 132 138 144 150 156 162 168 174 180 186

5'7" 134 140 146 153 159 166 172 178 185 191 198

5'9" 142 149 155 162 169 176 182 189 196 203 209

BODY MASS INDEX

  21 22 23 24 25 26 27 28 29 30 31

5'11" 150 157 165 172 179 186 193 200 208 215 222

6'1" 159 166 174 182 189 197 204 212 219 227 248

6'3" 168 176 184 192 200 208 216 224 232 240 248

*Weight is measured with underwear but not shoes.

BMI values for selected heights between 4'10" and 6'3" and for selected weights between 100 lbs and 248 lbs. BMI values are kilograms of body weight per square meter of body surface area (kg/m2). BMI is an indirect measure of body fat. The BMI of a normal person is 18.5 to 24.9 kg/m2. An overweight person has a BMI of 25 to 29.9 kg/m2. An obese person has a BMI of >30 kg/m2. ()

The most effective way to lose weight and to maintain the lower weight is by

participating in a comprehensive weight-loss program that combines low-

calorie diets, behavior modification, and regular exercise. Physicians and nurses

can encourage their patients in the difficult task of losing weight by checking a

patient’s BMI and waist circumference at each follow-up visit (Antman et al.,

2007; Fraker et al., 2007).

Increase Physical Activity

Regular exercise helps to correct dyslipidemia. It also reduces insulin

resistance, decreases platelet aggregation, aids weight loss, improves sleep, and

gives people a sense of well-being. Regular physical exercise is recommended

for ischemic stroke patients who are capable of it. A common recommendation

is 30 minutes of moderate-intensity activity on at least three different days each

week (Furie et al., 2009). (Brisk walking is an example of a moderate-intensity

physical activity.) For patients who have neurological deficits after an ischemic

stroke, a supervised therapeutic exercise program is usually recommended

(Summers et al., 2009).

PHYSICAL REHABILITATION

After a stroke, a patient may no longer fit into the environment and lifestyle that

they were living before they became ill. Previously, they may have been

entirely independent, able to go to the bathroom, and able to dress, eat, and

travel without assistance. They could talk on the phone, write letters, and figure

out their finances by themselves. Some or all of these tasks may now be beyond

them. Post-stroke rehabilitation programs ease a patient into a lifestyle that

gives them optimal independence and protection.

Physical rehabilitation is needed because strokes commonly lead to functional

limitations. Patients can be left with motor deficits, such as difficulty walking,

speaking, or swallowing, and they can find themselves unable to perform the

basic activities of daily living without assistance. Patients can also be left with

sensory deficits, such as disturbances of vision or balance or a lack of

perception of pain from injuries. Patients can lose cognitive abilities and

become forgetful, inattentive, or unable to learn. Stroke patients can have

reduced mobility and reduced ability to communicate, they can be incontinent

and unable to function sexually, and their post-stroke lives can become narrow,

constricted, and asocial.

For a stroke patient older than 65 years, 6 months after a stroke:

30% will need assistance when walking 26% will need assistance with activities of daily living 26% will be living in a nursing home (Stein, 2008)

Physical rehabilitation programs aim to reactivate and broaden a stroke

patient’s life. The rehabilitation goals are to restrengthen the patient’s

weakened muscular, sensory, and cognitive facilities and to teach the patient

ways around those neurological deficits that cannot be reversed.

Improving Movement

Strokes frequently reduce a patient’s independence by leaving them unable to

perform certain movements. For example, they may no longer be able to grasp

things with a hand, balance when standing, or walk without assistance.

Overall, 65% to 75% of stroke patients will recover sufficiently to be able to

walk, although some will be dependent on braces, support, or other assistance.

However, to become ambulatory, patients who have motor deficits need regular

range-of-motion exercises throughout the 3- to 4-month period during which

their nervous systems are actively recovering. Standing and walking should be

practiced as soon as possible. In some cases, electrical stimulation of muscles

can help to retain muscle strength and to keep joints fully moveable (Sawyer,

2007).

Compared to recovery for walking, fewer patients recover satisfactory function

in an upper extremity that has been disabled by a stroke. As many as 1/3 of

stroke patients who have significant dysfunction in their upper limb will not

improve significantly and will always have a functionless limb (Sawyer, 2007).

REHABILITATING MOTOR FUNCTIONING

The key to improving any of the lost motor functions is physical rehabilitation.

There is a wide range of specific physical rehabilitation programs, but they are

all based on movement and exercise. The most common therapeutic exercise

programs focus on practical achievements, aiming to make stroke patients more

mobile and more independent when performing their actual normal activities of

daily living (Stein, 2008).

Many training techniques have been developed for motor function

improvement, but no one path to functional improvement has emerged as the

standard for stroke rehabilitation (Kalra, 2010). There are, however, commonly

agreed-upon principles. A recent comprehensive review found that all effective

exercise techniques for reducing motor impairments and improving motor

functioning share these four features:

Task specific. The exercises are variants of the actual motor task to be improved, rather than targeting individual muscles, unusual movements, or overall fitness.

High intensity. The level of the exercise activity is pushed toward the high end of what can be expected from the patient.

Repetitive. The exercise is repeated many times in a single session. Combined with feedback on performance. The patient is given immediate

feedback as to the level of performance of each repetition of the exercise.

Regardless of the particular muscles or skills to be improved, exercises

designed to meet these four criteria appear to be the most effective (Langhorne

et al., 2009).

Therapeutic exercise improves the muscles and the lower motor neuron circuits

used in the task that is exercised. In addition, the best exercises work more

centrally: effective physical therapy appears to act as a guide for the cortical

reorganization that is part of the brain’s innate recovery from a stroke.

Frontier research continues to discover details about the interactions between

exercise and neural reorganization, and the new insights are being used to

design novel physical therapy techniques, such as using virtual reality in

exercise training (Stein, 2008).

STABILIZING JOINTS

Contracting a single muscle will lead to a ballistic, uncontrolled movement; to

make a controlled movement, it is necessary to simultaneously activate

opposing muscles. After a stroke, the weakness or paralysis of muscles can

impair the use of the opposing muscles, and movements produced by the

opposing muscles will be poorly controlled.

This problem is especially apparent at joints, where opposing muscles are used

as stabilizers to limit movement in unwanted directions. At joints, the lost

muscular opposition can sometimes be replaced by braces or splints. (Braces

and splints can be bulky, awkward, or heavy; to be used effectively, these

assistive devices need to be lightweight, comfortable, and cosmetically

acceptable.)

For example, selective bracing can improve walking after a stroke that has

affected the motor functioning of a lower limb. Both hip and knee joint

movements can be impaired in hemiplegia, but it is imbalance and instability at

the ankle joint that most limits walking. For instance, after a stroke, the

equinus deformity of the ankle is common; here, muscle weaknesses leave the

foot excessively plantar-flexed. To counteract the weakened ankle dorsiflexors

(or, sometimes, the hypertonic ankle plantar-flexors), the patient can wear ankle

braces (i.e., lightweight ankle-foot orthoses) to hold the ankle joint in a normal

position and significantly improve walking. When bracing is not successful,

surgical release of the gastrocnemius fascia can ease the plantar-flexion of an

equinus deformity (Takahashi and Shrestha, 2002).

USING ASSISTIVE TECHNOLOGIES

Besides braces, a wide array of technical aids is available to assist stroke

patients in overcoming neurological deficits. For mobility, for example,

walking can be assisted with canes and walkers. Hemi-wheelchairs, which are

low to the ground, allow patients to use their own legs for propulsion. Power

wheelchairs and motorized scooters require no lower limb muscles and can be

driven using hand controls.

The engineering of assistive technologies is a creative and promising field.

Research has shown that patients’ brains can directly interface with robotic

devices to control upper and lower limbs for tasks such as walking and handling

objects. The hope is that these devices will eventually become commercially

available (Stein, 2008; Kalra, 2010).

Improving Sensation and Cognition

Besides causing motor deficits, strokes can leave a patient with impaired vision

or with reductions in somatic or visceral sensation; it is estimated that 60% of

stroke patients have sensory impairments. Glasses, hearing aids, and other

assistive devices have long been used to compensate for such sensory deficits.

Recent work has taken stroke therapists in a new direction. There is now

evidence that more complex sensory and cognitive problems caused by a stroke

can be repaired.

For example, hemianopia (the loss of vision in 1/2 of the visual field in one or

both eyes) is now being treated directly with a range of new techniques. One

technology uses prismatic lenses to project some of the lost visual world onto

the functional part of the retina; this reduces the amount of visual space that is

hidden by the hemianopia. Another technique widens the accessible visual

space by training patients to increase their natural saccades (spontaneous small

visual jumps made by the eye); wider saccades take in more of the visual space

and increase the patient’s field of vision. In small studies, both of these new

techniques appear to be effective (Kalra, 2010).

Cognitive abilities can also be impaired by strokes. Patients can have decreases

in memory, attention, insight, or comprehension. Neuropsychological

assessments done before a stroke patient is discharged can identify many of

these problems and alert stroke rehabilitators to specific problems that need

work. For example, classifying aphasia early allows patients to be enrolled in

appropriate rehabilitation programs, many of which utilize specialized

computer software for visual word manipulation or speech synthesis.

Cognitive evaluations are especially useful when counseling patients’ families

and caregivers. Stroke victims may not be the same bright and independent

people that they once were; now they may appear forgetful, depressed,

irrational, or aphasic. The family can be overwhelmed by the changes and

unable to sort out the true deficits from the secondary effects of those deficits.

Rehabilitators can help by being both realistic and constructive. To make

improvements in a patient’s cognitive abilities, rehabilitation programs must

work at the level at which the patient is currently functioning. Therefore,

rehabilitators, who can see the patient more objectively than close family or

friends, must give families and caregivers a realistic evaluation of the patient.

Additionally, rehabilitators should offer a list of specific and practical actions

that family and caregivers can do to help the patient to progress (Stein, 2008).

SUMMARY

Recovery from a stroke usually requires long-term coordinated and continuing

medical and physical rehabilitation. Nonetheless, rehabilitation workers should

remain hopeful—even patients who have been left with severe disabilities from

their stroke will still be gradually improving >5 months afterward.

Patients recover from strokes because of the ability of the brain to learn new

ways to accomplish old tasks. This learning takes time, and medical

rehabilitation tries to maintain a patient’s health during that time by, among

other things, preventing additional strokes.

Meanwhile, physical rehabilitation tries to maximize the speed at which the

brain retrains itself and to substitute tasks that are more manageable for those

functions that cannot be relearned. In other words, physical rehabilitation

programs aim to reactivate and broaden a stroke patient’s life.

RESOURCES

American Stroke Association (A Division of American Heart Association)

http://www.strokeassociation.org

Brain Aneurysm Foundation

http://www.bafound.org

Brain Attack Coalition

http://www.stroke-site.org

Internet Stroke Center

http://www.strokecenter.org

National Aphasia Association

http://www.aphasia.org

National Institute of Neurologic Disorders and Stroke

http://www.ninds.nih.gov/disorders/stroke/stroke.htm

National Stroke Association

http://www.stroke.org

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