Stroke rehabilitation: Road to recovery

Stroke is one of the leading causes of long-term disability in the Philippines. Thousands of Filipinos are living with the effects of stroke. These effects may mean that you must change, relearn or redefine how you live. The goals of rehabilitation are to build strength, capability, and confidence so that you can continue your daily activities despite possible impairments. New discoveries and techniques may enhance the recovery process. In the future, these advances may even allow for the repair or replacement of damaged brain cells.

What Happens In The Brain

Stroke occurs when the supply of blood that normally nourishes the brain is reduced. It can happen in two ways — when blood flow to brain tissue is blocked, or if blood leaks into the brain or into tissues surrounding the brain. Stroke affects brain cells that send signals controlling almost every function in the body (see illustration). When brain tissue is damaged, it can have far-ranging effects including:

• Physical. Paralysis, stiffness, weakness, a loss of feeling or lack of coordination may affect your face, arm or a leg, or an entire side of your body. You also may have balance problems; visual deficits, including blindness in one or both eyes; or trouble speaking or swallowing.

• Cognitive. The way you think, remember or interact with others or perceive the world around you may be affected. Perceptual changes may make it harder for you to understand what you feel, see or hear. You may also have difficulty understanding what you read or what people say.

• Psychological. Stroke can affect you by damaging an area of your brain that’s involved in producing emotions. You may feel helpless, frustrated, and uninterested in activities you once enjoyed. You may cry or laugh more easily or have sudden mood swings for no apparent reason. Depression, grief, irritability, and fatigue sometimes occur.

Helping Achieve Independence

The outlook for stroke rehabilitation is better today than ever before. After a stroke, some people experience a complete or nearly complete recovery. Still, approximately half of stroke survivors will be left with some kind of permanent disability. The success of rehabilitation depends on many factors, including:

• It’s timing. The earlier rehabilitation begins, the more likely you are to regain lost abilities and skill.

• The extent of brain injury. People with milder injuries are likely to benefit the most. But even with slight improvement, rehabilitation can mean the difference between functioning independently and needing assistance for your activities.

• It’s intensity and frequency. Studies suggest that greater intensity and frequency of therapy improve functional outcomes. Even if rehabilitation sessions are scheduled only a few times a week, therapeutic exercises should be done on a daily basis.

• Your outlook and attitude. Motivation and a positive attitude are key to obtaining an optimal level of recovery. Rehabilitation requires a willingness to work hard.

• The cooperation of friends and family. Companionship and emotional support are essential to rehabilitation. Caregivers also play an important role in assisting with rehabilitation exercises and therapies, and helping you maintain improvement.

What Is Involved

The purpose of rehabilitation is to reach the highest possible level of independence. What you do in rehabilitation depends on what skills you need to become independent. A major part of rehabilitation is often physical training and therapy. This may involve training with mobility skills, such as relearning to walk or learning to self-propel a wheelchair; balancing skills; and maximizing the range of motion in your joint.

Rehabilitation may also involve relearning self-care skills — including eating, grooming, bathing, and dressing — or learning to adapt how you perform these tasks to compensate for your disability. Addressing cognitive skills, including memory and problem solving, and communication and social skills are also important parts of rehabilitation. You may also learn how to reorganize your living space to make it safer and more accessible.

Because numerous impairments may be involved, rehabilitation is facilitated by a diverse team, which may include doctors specializing in physical medicine and rehabilitation (physiatrists), physical therapists, occupational therapists, speech-language pathologists, psychologists, rehabilitation nursing, social workers, and others. Although each team member lends particular expertise, the team works together to help recovery.

Advances

The brain was once thought to be a static organ — brain cells could die but not be repaired or regained. In recent years, due to research studies and advances in brain imaging techniques, doctors and researchers are gaining a new understanding of how brain systems adapt after stroke to regain function (brain plasticity).

After injury, efforts are geared towards maximizing function in spite of the damaged brain. In some research models, scientists observed the brain cells surrounding a damaged area undergo changes in function and shape that allow them to take on the functions of the damaged cells. Results indicate that similar changes occur in human brains after a stroke and other trauma.

Researchers have hypothesized that stem cells one day may enable damaged brain areas to recover their function. Other therapies to encourage the regeneration of damaged brain cells are also being explored. Many other recent advances may play a role in retraining injured areas of the brain and helping to stimulate use of paralyzed or weakened areas of the body. Other advances include:

• Constraint-induced therapy. This therapy involves restricting the use of an unaffected or less affected limb while intensively training the more-affected limb. This helps improve limb function.

• Forced-use therapy. With conventional forced-use therapy, therapists manually assist with thousands of movement repetitions to help the injured brain relearn how to accomplish tasks with an impaired limb. Researchers are exploring the use of robots to assist with these movements.

• Electrical stimulation and biofeedback. Functional electrical stimulation involves the use of electricity to stimulate muscles weakened or paralyzed by a stroke to cause them to contract. In biofeedback, a sensor is placed over a target muscle, and when that muscle is successfully moved, the electrical activity generated by that muscle is picked up by the sensor and used to provide biofeedback to the individual. The goal is to help a stroke survivor become more aware of the means to move the target muscle and achieve the movement more easily. Some rehabilitation facilities combine these two methods to speed muscle and nerve retraining.

• Cortical simulation. With this technique, an electrical current is used to stimulate the motor cortex in the brain. Studies have shown that it improves the performance of a paralyzed limb. However, it hasn’t yet been approved for clinical use.

• “Wiihabilitation.” Many stroke patients require interactive physical therapy, which they may find boring and sometimes painful. But doctors have found that Nintendo’s Wii video game system, is an excellent substitute as the game’s motion-sensitive controller requires body movements similar to traditional therapy but provides so much distraction and more enjoyment for stroke patients. Rehab doctors in the Philippines have started to use it to help stroke patients regain movement in their arms and legs. The local experience, for example, at the Department of Rehabilitation Medicine at the Cardinal Santos Medical Center, had been favorable.

In addition to these therapies, pioneering work is being done in the area of virtual reality. These simulations and training methods encourage the brain to reorganize to compensate for the damage. They’re designed to improve range of motion, balance, strength, and other measures of motor function.

However, none of these treatment methods has been shown to be significantly better than willful, task-specific practice of a motor behavior. A willingness to work towards improvement is one of the most important ingredients of successful rehabilitation. –Tyrone M. Reyes, M.D., Philippine Star