Stroke Rehabilitation, Types, Recovery, Go To Works

What disabilities can result from a stroke?/Stroke Rehabilitation?

The types and degrees of disability that follow a stroke? depend upon which area of the brain is damaged. 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 (one-sided weakness? is called hemiparesis).
• 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 the 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 a 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.

What medical professionals specialize in post-stroke rehabilitation?

• 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 downstairs 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.

References

1. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Post-Stroke-Rehabilitation-Fact-Sheet