Revolutionary approaches to stroke recovery
March 12, 2002 | 12:00am
Stroke is one of the most traumatic medical events we may ever face. But even though stroke is a formidable foe, intensive rehabilitation programs can help "rewire" itself and overcome damage – sometimes to a greater degree than expected. "When you’re treating an individual, basically anything can happen," says Ofelia L. Reyes, M. D., chairman of the Department of Rehabilitation Medicine at the Cardinal Santos Medical Center. "Sometimes you are surprised."
During a stroke, the brain’s blood supply is interrupted. In a hemorrhagic stroke, a break in a cerebral artery causes bleeding. In an ischemic stroke, the more common type, a blood clot blocks an artery. As a result, brain cells are starved of oxygen and they begin to die.
The extent and location of the damage largely determines a stroke victim’s prospects for recovery. This is why it’s so important to recognize the signs of stroke and get medical attention immediately. In the event of an ischemic stroke, special clot-dissolving medications – if administered in time – can restore blood flow and reduce brain damage. As a general rule, 90 percent of the damage occurs in the first three hours. Getting to a hospital within an hour gives doctors time to diagnose and treat a clogged cerebral artery.
The mental and physical impairments caused by a stroke depend on which areas of the brain suffer damage. The stroke may affect any of the specialized areas for movements, language, higher thought, and sensation, affecting the person’s ability to walk and perform day-to-day tasks. Disabilities that stroke victims may face include:
• Paralysis or weakness, usually on one side
• Difficulty understanding or using language
• Abnormal sensation and pain
• Impairments in thinking, learning, awareness, and memory
• Emotional disturbances, especially post-stroke depression
One of the immediate concerns of stroke survivors and their families is how complete a recovery is possible. This can be difficult to predict. "The earlier you start to recover, generally the better you do," Dr. Reyes says. "But if you don’t start to recover for several weeks or a month, that doesn’t mean you’re not going to make any improvement."
The brain possesses a certain degree of "plasticity," or an ability to repair damage by recruiting unharmed areas of the brain. This allows a person in rehabilitation to "retain the brain" through focused, repetitive practice of the sort required to learn how to play the piano or excel in a sport.
The rehabilitation process begins as soon as the person’s medical condition is stable – usually within two to three days after the stroke. the medical team that provides rehabilitation includes doctors (usually specialists in Rehabilitation Medicine called physiatrists), nurses, and a battery of specialized therapists. Physical therapists, for example, address difficulties with movement, balance, and coordination. Occupational therapists coach their patients on how to perform day-to-day skills, such as eating and dressing. And speech-language pathologists focus on improving language skills.
One major goal of stroke rehabilitation is to help people relearn or compensate for mental and physical skills lost due to brain damage. "But it’s more than that," Dr. Reyes emphasizes. "It’s also to help the person return to some level of independence." With proper care and the support of friends and family, even people with severe neurological impairments, such as memory loss, can function on a day-to-day basis.
After the acute rehab care, the therapy usually shifts to either out-patient or home-based treatments, where rehabilitation continues for a number of months. But even after the supervised rehabilitation, the recovery process is not necessarily over. "If you have pneumonia and you’re on antibiotics for two weeks, you get better," Dr. Flanagan says. "If you have a stroke, the recovery lasts months, sometimes years."
The brain’s ability to heal isn’t limitless, but stroke survivors and their families and caregivers can still influence the recovery process.
One of the most important things is to recognize post-stroke depression and get treatment for it. Understandably, stroke survivors may initially feel sad or hopeless about their situation. This saps the patient’s motivation, slowing his recovery. But depression is treatable. And people treated for depression ultimately do better than those who remain depressed.
Finally, perhaps the most helpful factors of all are the patience and persistence of stroke survivors and their caregivers. Generally, you see a lot of improvement earlier on, and after a few months the recovery tends to slow and you may not see improvements on a day-to-day, or even a week-to-week, basis. You may see it instead on a month-to-month basis. Those who continue to work hard, exercise at home, and try to do things for themselves may notice more improvements over a longer period of time.
Certain medications, scientists found out last year, may boost the effectiveness of physical and speech therapy in stroke patients. Amphetamines (e.g. Dexedrine) and levodopa (e.g. Sinemet), drugs normally used to treat Parkinson’s disease, may enhance stroke rehabilitation therapy.
In the first study published in the September 2001 issue of Stroke, patients given Dexedrine a half hour before speech and language training sessions "performed significantly better than those in the placebo group." In another study, published in the September 8, 2001 issue of Lancet, patients who received Sinemet before their physical therapy sessions had "better overall mobility and better control of their arms than those in the placebo groups."
Amphetamines and levodopa both increase the levels of neurotransmitters called norepinephrine in key brain areas, so the same chemical may be responsible for the effects of both drugs on stroke recovery. In the brain, norepinephrine regulates mood and helps focus attention and process complex thought. It may also enhance permanent cellular changes that represent learning.
But doctors don’t know yet exactly which dosages are ideal, how long the drugs should be given, or whether the drugs are effective only during a limited time window. The Lancet and Stroke studies support the potential benefit of the norepinephrine approach. However, its long-term clinical significance for the stroke victim’s daily life remains to be studied, and whether all types of stroke patients will benefit remains uncertain. More, the effects of the drug may wane over time. Two larger trials, funded by the U S National Institutes of Health, should be able to tell us later how to make the most of the norepinephrine therapy. Meanwhile, although amphetamines and levodopa are available by prescription for other disorders, doctors should not prescribe them for this purpose in stroke patients until further research is completed.
The next few years promise to shed more light on several other new approaches to stroke recovery. Scientists are investigating whether hormone replacement therapy might help women recover after a stroke. Others are studying how physical therapy using a robotic arm to direct the patient’s movement can improve limb control. New physical therapy techniques, including treadmill training for treating poststroke walking deficits and constraint-induced movement therapy (as discussed in this column last Feb. 27, 2001) for improving hand and arm function, are also under investigation.
"We are on the brink of a revolution in stroke rehabilitation," predicts Dr. Edward Taub of the Department of Rehabilitation Medicine of the University of Alabama. Indeed, the results of all these studies and researches add to a growing body of evidence that the brain is extraordinarily resilient and that it is capable of growth throughout life!
The extent and location of the damage largely determines a stroke victim’s prospects for recovery. This is why it’s so important to recognize the signs of stroke and get medical attention immediately. In the event of an ischemic stroke, special clot-dissolving medications – if administered in time – can restore blood flow and reduce brain damage. As a general rule, 90 percent of the damage occurs in the first three hours. Getting to a hospital within an hour gives doctors time to diagnose and treat a clogged cerebral artery.
The mental and physical impairments caused by a stroke depend on which areas of the brain suffer damage. The stroke may affect any of the specialized areas for movements, language, higher thought, and sensation, affecting the person’s ability to walk and perform day-to-day tasks. Disabilities that stroke victims may face include:
• Paralysis or weakness, usually on one side
• Difficulty understanding or using language
• Abnormal sensation and pain
• Impairments in thinking, learning, awareness, and memory
• Emotional disturbances, especially post-stroke depression
The brain possesses a certain degree of "plasticity," or an ability to repair damage by recruiting unharmed areas of the brain. This allows a person in rehabilitation to "retain the brain" through focused, repetitive practice of the sort required to learn how to play the piano or excel in a sport.
One major goal of stroke rehabilitation is to help people relearn or compensate for mental and physical skills lost due to brain damage. "But it’s more than that," Dr. Reyes emphasizes. "It’s also to help the person return to some level of independence." With proper care and the support of friends and family, even people with severe neurological impairments, such as memory loss, can function on a day-to-day basis.
After the acute rehab care, the therapy usually shifts to either out-patient or home-based treatments, where rehabilitation continues for a number of months. But even after the supervised rehabilitation, the recovery process is not necessarily over. "If you have pneumonia and you’re on antibiotics for two weeks, you get better," Dr. Flanagan says. "If you have a stroke, the recovery lasts months, sometimes years."
One of the most important things is to recognize post-stroke depression and get treatment for it. Understandably, stroke survivors may initially feel sad or hopeless about their situation. This saps the patient’s motivation, slowing his recovery. But depression is treatable. And people treated for depression ultimately do better than those who remain depressed.
Finally, perhaps the most helpful factors of all are the patience and persistence of stroke survivors and their caregivers. Generally, you see a lot of improvement earlier on, and after a few months the recovery tends to slow and you may not see improvements on a day-to-day, or even a week-to-week, basis. You may see it instead on a month-to-month basis. Those who continue to work hard, exercise at home, and try to do things for themselves may notice more improvements over a longer period of time.
In the first study published in the September 2001 issue of Stroke, patients given Dexedrine a half hour before speech and language training sessions "performed significantly better than those in the placebo group." In another study, published in the September 8, 2001 issue of Lancet, patients who received Sinemet before their physical therapy sessions had "better overall mobility and better control of their arms than those in the placebo groups."
Amphetamines and levodopa both increase the levels of neurotransmitters called norepinephrine in key brain areas, so the same chemical may be responsible for the effects of both drugs on stroke recovery. In the brain, norepinephrine regulates mood and helps focus attention and process complex thought. It may also enhance permanent cellular changes that represent learning.
But doctors don’t know yet exactly which dosages are ideal, how long the drugs should be given, or whether the drugs are effective only during a limited time window. The Lancet and Stroke studies support the potential benefit of the norepinephrine approach. However, its long-term clinical significance for the stroke victim’s daily life remains to be studied, and whether all types of stroke patients will benefit remains uncertain. More, the effects of the drug may wane over time. Two larger trials, funded by the U S National Institutes of Health, should be able to tell us later how to make the most of the norepinephrine therapy. Meanwhile, although amphetamines and levodopa are available by prescription for other disorders, doctors should not prescribe them for this purpose in stroke patients until further research is completed.
The next few years promise to shed more light on several other new approaches to stroke recovery. Scientists are investigating whether hormone replacement therapy might help women recover after a stroke. Others are studying how physical therapy using a robotic arm to direct the patient’s movement can improve limb control. New physical therapy techniques, including treadmill training for treating poststroke walking deficits and constraint-induced movement therapy (as discussed in this column last Feb. 27, 2001) for improving hand and arm function, are also under investigation.
"We are on the brink of a revolution in stroke rehabilitation," predicts Dr. Edward Taub of the Department of Rehabilitation Medicine of the University of Alabama. Indeed, the results of all these studies and researches add to a growing body of evidence that the brain is extraordinarily resilient and that it is capable of growth throughout life!
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