Stroke

Description

Alternative Names

Recovery

Patients should begin all measures, including any medications and life-style changes needed to prevent another stroke. For those whose stroke was ischemic, aspirin, warfarin, or both will usually be prescribed.

Using a neurologist as the primary physician after a stroke, rather than some other specialist or primary care doctor, significantly increases the chance for survival. In any case, patients or their families should be persistent in requesting the best care possible during this important early period.

Being treated initially in a stroke unit instead of a general ward plays a strong role for better long-term quality of life. Rehabilitation services aimed at patients living at home are also very effective in improving independence. Unfortunately, Medicare cuts are making it difficult to obtain adequate rehabilitation. Patients or their families should seek patient advocates or support associations.

Reducing the Risk for Non-Neurologic Complications after a Stroke

In addition to problems brought on by neurologic damage, stroke patients are also at risk for other serious problems that reduce their chances for survival. They include the following:

• Blood clots in the legs (deep vein thrombosis).
• Pulmonary embolism (a blood clot that travels to the lungs).
• Pneumonia.
• Widespread infection.
• Heart problems.
• Urinary tract infections.

Measures should be taken to monitor and treat patients for these important problems.

Candidates for Rehabilitation

In all, 90% of stroke survivors experience varying degrees of improvement after rehabilitation. With current cost cutting, there is pressure to send elderly stroke victims directly to a nursing home rather than try rehabilitation first, although one study found that patients were three times more likely to return home from rehab units than from nursing homes. Not all patients, however, need or benefit from formal rehabilitation:

• If the stroke is severe, intensive training would not be very helpful
• If the stroke is mild, patients often improve on their own.

Positive factors that help predict good candidates for rehabilitation:

• A patient should be able to sit up for at least an hour.
• The patients should be able to learn and be aware.
• Spasticity may be a good sign, because it indicates live nerve action.
• Patients who are able to move their shoulders or fingers within the first three weeks after having a stroke are more likely to recover the use of their hands than patients who cannot perform these movements. The ability to feel light pressure on the affected hand, however, makes no difference for future hand movement.
• Family members or close friends are available to be active participants in the rehabilitation process.

Factors that might predict a poor response to rehabilitation:

• Dysphagia (the inability to swallow) is associated with a higher mortality rate, possibly because of increased risk for infection and malnutrition. (Dysphagic patients who are given nutrition using a stomach tube may improve more than those who are fed using a feeding tube inserted down through the nose.)
• Incontinence.
• The inability to recognize nonspeech sounds that occur right after a stroke.
• A poor hand grip that is still present after three weeks is an indicator of severe problems.
• Having had very severe seizures after the stroke.

Factors that do not rule out rehabilitation:

• About 30% of patients experience aphasia (an impaired ability to speak), which is particularly distressing. It is necessary to understand that this disability does not necessarily impair the ability to think.
• Although confusion is common among people who have had strokes, partial or even complete recovery is very possible.

Some Approaches to Rehabilitation

Physical therapy should be started as soon as the patient is stable, as early as two days after the stroke. Some patients will experience the fastest recovery in the first few days but many will continue to improve for about six months or longer. Because stroke affects different parts of the brain, specific approaches to managing rehabilitation vary widely among individual patients:

• Retraining muscles. One approach is based on training different muscles to replace those that have been impaired by damaged brain cells. In one small but important 2000 study, 13 stroke victims who had right-side paralysis had their non-paralyzed arm immobilized so that they were forced to use their paralyzed arm. Eleven of the patients experienced improvement in their impaired arms. The affected side of their brains also appeared to become more active. More studies are necessary. Physical exercise relating to the disability caused by the stroke is, in any case, important and may actually help repair the brain.
• Speech therapy and sign language. Intense speech therapy (about 9 hours a week for three months) after a stroke is important for recovery. (The less intense the program the less chance for success.) While professional speech therapy progresses, the patient's caregivers should use and encourage the patient in non-verbal communications, such as pantomime, facial expressions, and pen and paper. Learning and using the sign-language alphabet may be helpful both in communicating and improving small-motor dexterity.
• Biofeedback techniques combined with physical therapy. This combination has been beneficial in certain cases. Electrical stimulation of the throat, for example, may help patients with dysphagia recover their ability to swallow faster. Stimulation of the wrist and finger is also showing promise for improving motor capabilities.
• Swallowing exercise. A very promising 2002 study reported that swallowing improved when patients performed a simple exercise three times a day for six weeks. They lay flat and raised their heads three times, holding them up for one minute with a minute rest in between. This was followed by 30 consecutive head lifts.
• Attention training. Problems in 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 skills. For example, in one study, small electric cars were used in a lab to teach driving.
• Occupational training. Occupational therapy is important and improves daily living activities and social participation.

Drug Therapy for Rehabilitation

Drug therapy can sometimes help relieve specific effects of stroke:

• Dantrolene (Dantrium), baclofen, and botulinum (Botox) injections have shown some promise in relieving spasticity.
• In one small study, the drug bromocriptine (Parlodel), normally used for Parkinson's disease, was helpful for patients with severe speech problems, improved their ability to pronounce multi-syllable words and to form sentences.
• Some patients experience intractable hiccups, which can be very serious. Among the drugs used for this condition are chlorpromazine or baclofen.
• Studies have reported that dextroamphetamine or methylphenidate (Ritalin), an amphetamine used in attention deficit disorder, may help patients recover speech and motor skills when combined with physical therapy.

Certain drugs commonly taken for conditions associated with stroke may actually slow recovery. They include drugs used for high blood pressure, including clonidine and prazosin, anticonvulsant drugs, the antipsychotic drug haloperidol, and the common anti-anxiety drugs benzodiazepines.

Managing the Emotional Consequences

The Emotional State of the Patients. Strong motivation with the goal of independence after rehabilitation is important for recovery. Unfortunately, depression is very common after a stroke, both as a direct and indirect result of the stroke:

• Strokes that affect the right hemisphere in the brain particularly increase the risk for depression.
• Patients can certainly become depressed by the great changes in their ability to function.
• A peculiar stroke-induced condition, known as post-stroke crying or neurologic emotionalism, is a neurologic not a psychologic disorder.

If depression is prolonged, it can impair recovery. One study showed that people who suffered strokes and became depressed were three times more likely to die within ten years than stroke victims who were not depressed. There is a significantly increased risk of suicide in patients with stroke, especially in women and those under age 60.

Antidepressants, particularly fluoxetine (Prozac) and similar so-called SSRI drugs, have been beneficial in relieving post-stroke crying and to improve recovery in general, and mood in particular, in patients who are depressed. Antidepressants may also help restore mental abilities.

Some physicians also recommend agents called tricyclic antidepressants, including amitriptyline (Elavil) and nortriptyline (Pamelor). In one 2000 study nortriptyline (Pamelor) not only improved mood but also had positive effects on mental functioning, suggesting perhaps that some dementia associated with stroke may actually be due to depression. Tricyclics may also be useful for neurologic emotionalism.

Anxiety disorder is also common and debilitating. Some research, in fact, indicates that many patients suffer from feelings identical to post-traumatic stress syndrome. The two disorders often overlap, but drug treatments for each differ and may offset the other.

It should be noted that many drugs for psychologic disorders affect the central nervous system and can actually delay rehabilitation. Skilled professional help is needed to determine the most effective and safest treatments.

The Emotional State of the Caregiver. The caregiver's emotions and responses to the patient are critical. Patients do worse when caregivers are depressed, over-protective, and not knowledgeable about the stroke. Unfortunately, in one study, over half of the caregivers themselves were depressed, particularly if the stroke victims were left with dementia or abnormal behavior.