Post-Stroke Recovery: Helping the Brain Fight Back
September 2009 Issue
Types of Stroke
There are two main types of stroke.
Ischemic stroke occurs when a blood vessel clogs from within and impedes flow to the brain. About 85 percent of all strokes are ischemic.
Hemorrhagic stroke occurs when a blood vessel ruptures within the brain. While only about 13 percent of all strokes are hemorrhagic, they are responsible for more than 30 percent of all stroke deaths, according to the National Stroke Association.
Transient ischemic attacks (TIAs) are minor strokes in which typical stroke warning signs develop, but the blood
clot occurs fairly briefly and resolves through normal body mechanisms. TIAs are strong indicators of a possible major stroke, and steps should be taken immediately to prevent a stroke, warns the American Stroke Association, a division of the American Heart Association.
Faye, a happily married homemaker in her 60s, was chatting on the telephone, when, as she recalls, "I knew what I was trying to say in my mind, but all that was coming out of my mouth was gibberish. I didn't know what was happening," she told The O&P EDGE.
Kate, 33, also happily married with a loving husband, two children, and a beautiful home in a beach town, was making preparations to start her own business when she suddenly felt dizzy. Within minutes, she was trapped in her own body-totally awake and aware, but unable to scream or even to speak (Stroke Smart Magazine).
Both women had fallen victim to stroke, also known as a cerebrovascular accident (CVA), and eventually both recovered.
Although stroke is primarily a disease of the elderly, it can occur in infants even before birth, children, adolescents, and adults under 50. Stroke is the third leading cause of death in the United States, killing 144,000 each year, and is a leading cause of serious, long-term adult disability. The National Stroke Association estimates that 795,000 strokes will occur this year, with estimated direct and indirect costs reaching $68.9 billion for 2009.
In stroke, vital blood and oxygen flowing to areas of the brain are stopped or limited. Symptoms can include sudden numbness or weakness; confusion; difficulties with speaking or understanding; trouble with walking, balance, and coordination; and a sudden severe headache.
When stroke hits, fast action is required. Two million brain cells die every minute during a stroke, increasing the risk of permanent brain damage, disability, or death. The ischemic cascade-cellular-level processes involved in stroke injury-begins within seconds to minutes of the loss of glucose and oxygen delivery to neurons, according to the article, "Acute Stroke Management," by Edward. C. Jauch, MD, MS, FAHA, FACEP, associate professor, Division of Emergency Medicine and Department of Neurosciences, Medical University of South Carolina, et al., eMedicine.com (www.emedicine.medscape.com). "Many factors are thought to result in cell death, and others are being discovered at a rapid rate."
|"As an orthotist, you need to integrate your plan with the overall team plan."|
Dan Hasso, CPO
Most adults who get treatment within a three-hour "golden window" may avoid significant brain damage. Studies have shown that tissue plasminogen activator (t-PA), a thrombolytic agent (clot-busting drug), significantly improves clinical outcomes for ischemic stroke patients, including reducing permanent disability, when it is administered within three to four-and-a-half hours after the onset of symptoms. Approved by the U.S. Food and Drug Administration (FDA) for certain patients suffering ischemic stroke, the drug must be administered within three hours under FDA rules.
Once the patient is medically stable, recovery and rehabilitation treatment can begin.
Currently, about 10 percent of stroke victims recover almost completely, 25 percent recover with minor impairments, 40 percent have moderate to severe impairments requiring special care, and 10 percent require care in a nursing home or other long-term care facility. About 15 percent die shortly after stroke.
For best outcomes, a growing body of evidence indicates that patients do better with a well-organized, multidisciplinary approach to post-acute rehabilitation after a stroke, notes the Practice Guidelines, Management of Adult Stroke Rehabilitation Care, developed by the Department of Veterans Affairs (VA) and Department of Defense (DoD), and endorsed by the American Heart Association/American Stroke Association.
Working with the Rehab Team
Stroke rehabilitation begins during the acute hospitalization phase, as soon as the diagnosis of stroke is established and life-threatening problems are under control.
|"A combined assessment and evaluation by the physical or occupational therapist and the orthotist is always optimal but not always convenient."|
Michael Davidson, CPO
"As an orthotist, you need to integrate your plan with the overall team plan," says Dan Hasso, CPO, who practices in the Naperville, Illinois, office of Scheck & Siress. For instance, only a simple device may be needed for limited household ambulation, but a more sophisticated device may be required for community ambulation. "If the plan calls for intense rehab, we may make a brace that provides considerable support early in the process, with the goal that a lighter, more flexible orthosis will be used after spasticity or other issues improve with rehabilitation and there is increased range of motion," Hasso explains.
Working closely with the therapist is vital so that the orthotist does not inadvertently impede therapy. Hasso appreciates the team approach because he can understand better how the orthosis fits in. "Otherwise, I could come up with a plan that I think will work well for the patient, but then I get a call from the therapist saying, 'This brace looks good and does about 85 percent of what I'm trying to do, but we just can't do that last 15 percent.'"
"It is important for the orthosis design to be within the goals identified for the patient, and that it doesn't contribute to any adverse effects," concurs Terry Supan, CPO, FAAOP, FISPO, president and CEO of Supan Prosthetic Orthotic Consultations, Rochester, Illinois. "For example, if the therapist wants the patient to place his or her foot in a certain position underneath a chair in order to rise from the chair, and the AFO is locked at 90 degrees at the ankle to resist knee flexion or hyperextension, the patient won't be able to."
"A combined assessment and evaluation by the physical or occupational therapist and the orthotist is always optimal but not always convenient," says Michael Davidson, CPO, Loma Linda University Medical Center, Outpatient Rehabilitation Center, Loma Linda, California. "By establishing a good rapport with therapists, orthotists can facilitate these 'co-treatments' that inspire collaboration."
AFOs are the most widely used orthoses in the United States, accounting for 26 percent of the clinical practice by certified orthotists, double that of any other type of orthosis, according to the 2007 Practice Analysis conducted by the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC), as reported in the Evidence Note, "The Use of Ankle Foot Orthoses in the Management of Stroke," American Orthotic & Prosthetic Association (AOPA), November 2008.
AOPA's Evidence Note lists the following conclusions:
- Studies generally indicate that gait symmetry improves with AFO use compared to walking without orthoses.
- AFOs with resistance to plantarflexion, whether articulated or nonarticulated, improve the ankle angle at initial contact and mid-swing.
- There is some indication that nonarticulated or plantarflexion-stop AFOs can control knee recurvatum and reduce the external knee extension moment during stance, especially if set in dorsiflexion or anterior tibial inclination.
- There is also some suggestion that non-articulated AFOs may control foot supination.
- A few studies have demonstrated that non-articulated AFOs decrease the energy cost of gait compared to walking without orthoses.
- Generally, subjects report that AFOs improve their walking and are comfortable.
"I look at an AFO like a seat belt," Hasso says. "It's there to prevent bad things from happening to you. If the patient has a weakness that could cause a fall, an AFO can help."
|"We cannot treat the underlying condition that the stroke created, but we should be able improve the patient's functional abilities."|
Terry Supan, CPO, FAAOP, FISPO
Some people complain that they are not getting better because they are not using their own muscles. "And that's true, they aren't using their own muscles-because if they could use their own muscles, they wouldn't need the brace," Hasso says. "There's exercise and therapy time versus just-going-about-your-daily-life time." Therapy/exercise time targets improvement, while daily life often requires orthotic support for safety, walking speed, and contracture prevention, he points out. "Yes, you may become dependent on the brace, but the dependence is directly related to the weakness or damage caused by your stroke. If we can solve the weakness, we can get rid of the brace, but if we can't solve the weakness, we need to rely on the brace for safety and more speed."
Orthotists treat the patient's current physical condition, with the goals of improving the patient's walking ability and trying to reduce any deforming muscle patterns, Supan says. "We need to remember that we cannot treat the underlying condition that the stroke created, but we should be able improve the patient's functional abilities."
He continues, "Not enough orthotists are involved with acute stroke care with the goal of preventing deformities before they develop. Most early orthotic care is provided in the rehabilitation phase when the patient's condition is changing and has gotten the best of the therapy team." Dealing with chronic orthotic care is usually a "maintenance" situation because the patient's condition has plateaued, he adds.
Classic orthoses for stroke evolved from polio treatments, Supan notes. "The flaccid paralysis of polio was easier to treat because we usually needed to provide function only in the sagittal plane. With the spasticity of more severe stroke conditions, "We need to be cognizant of the coronal and transverse planes as well."
The Brain Fights Back
|"A robotic device can provide treatment of specified duration and intensity that is not easy to do by hand, and thus take the burden off the therapist."|
W. Zev Rymer, MD, PhD
Studies are revealing new facts about the brain's amazing capacity to remodel and regenerate after stroke. For instance, an article in ScienceDaily reports, "Within weeks of a stroke, new blood vessels begin to form, and, like marching ants, newly born neurons migrate long distances to the damaged area to aid in the regeneration process." The article, published December 23, 2006, references a study, "A Neurovascular Niche for Neurogenesis after Stroke," by John J. Ohab, PhD, et al. (Journal of Neuroscience, December 13, 2006). In the mice used in the study, the neuron march was the direct result of signaling from the newly forming blood vessels. Although the process in humans may vary, it is known that neurogenesis occurs in humans, the article pointed out.
Another process involves the formation of new synapses. "Recent evidence indicates that the brain can remodel after stroke, primarily through synaptogenesis, according to "Stroke Rehabilitation: Strategies to Enhance Motor Recovery," by Michael W. O'Dell, et al. (Annual Review of Medicine, February 2009). "Task-specific and repetitive exercise appear to be key factors in promoting synaptogenesis and are central elements in rehabilitation of motor weakness following stroke."
This finding underscores the importance of using repetitive movements to retrain the brain and muscles during physical/occupational therapy.
"The brain is able to modify its structure and function according to experience and training," says W. Zev Rymer, MD, PhD, vice president, research, Rehabilitation Institute of Chicago (RIC), Illinois. "We see strong evidence of neuroplasticity in neurological studies," he adds, citing as an example musicians whose brain maps show enlargement of the brain region dealing with hands and fingers.
Technology to the Rescue
Advances in robotics and functional electrical stimulation (FES) are bringing new options to the therapist and the orthotist who are looking for new therapies and devices to help stroke patients regain function.
Treadmill training has proven effective in training patients to walk again, Rymer said. "But it is more effective if a physical therapist guides the movements of the limb. However, this is physically demanding, very labor intensive." A robotic device can provide treatment of a specified duration and intensity that is not easy to do by hand, and thus take the burden off the therapist, Rymer explains.
Noting that a motor-learning approach is the generally accepted method to retraining movement with neurologically impaired persons, Joseph Hidler, PhD, and colleagues in "Advances in the Understanding and Treatment of Stroke Impairment Using Robotic Devices," (Topics in Stroke Rehabilitation 2005), discuss specific devices and challenges facing robotic-therapy technology. "We propose that clinical acceptance in this field will come only after well-controlled studies are performed demonstrating the effectiveness of robotic devices," the authors conclude. "For each device, studies need to determine aspects of clinical application."
Functional Electrical Stimulation (FES)
Functional electrical stimulation uses electrical currents to activate nerves and thus excite the muscles they innervate to perform movements. FES has clinical application for various neurological disorders, including stroke, incomplete spinal cord injury, and head injuries.
FES has shown positive results in studies. For instance, a systematic literature review by Aisling Roche and colleagues at the University of Limerick Physiotherapy Department, Ireland (Physical Therapy Reviews, April 2009) supports the conclusion that FES can have a positive orthotic effect as a treatment for foot drop, especially in gait speed and physiological-cost index (PCI). However, research supporting a therapeutic effect was less conclusive.
Studies of FES upper-limb applications have likewise shown promise. Recent research conducted by Gad Alon, PhD, PT, et al., "Functional Electrical Stimulation Enhancement of Upper Extremity Functional Recovery During Stroke Rehabilitation: A Pilot Study," (Neurorehabilitation and Neural Repair, Vol. 21, No. 3, 2007) concluded, "Upper-extremity task-oriented training that begins soon after stroke that incorporates FES may improve upper-extremity functional use in patients with mild/moderate paresis more than task-oriented training without FES."
Constraint-Induced Movement Therapy (CIMT)
Developed by Edward Taub, PhD, a psychology professor at the University of Alabama, constraint-induced movement therapy (CIMT) focuses on retraining the brain to stop relying primarily on the unaffected arm, hand, or leg and once again perform tasks with the affected limb. Patients must have some movement in the affected limb. The therapy is most effective when it begins at least six months after a stroke and the patient has completed traditional rehabilitation, according to the University of Alabama Taub Therapy Clinic.
Patients treated with CIMT within three to nine months post-stroke demonstrated significant improvement within the first 12 months compared with participants who received traditional care, according to a study conducted by Steven L. Wolf, PhD, PT, FAPTA, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, and colleagues ("The EXCITE Trial: Retention of Improved Upper Extremity Function Among Stroke Survivors Receiving CI Movement Therapy," Lancet Neurology, 2008). Retention of improvement was assessed again at 24 months, with no regression observed.
Editor's note: For more information on robotics, FES, and CIMT, see "Walk This Way: Paths to Lower-Limb Recovery for Stroke Patients," and "Unlocking the Hand: The Changing Technology of Upper-Limb Orthotic Management for Stroke Patients."
Outlook for Stroke Survivors
This is only a sample of the research, evidence-based practice treatment protocols and guidelines, and new technology devoted to improving the recovery outlook for stroke patients. With the establishment of research foundations such as the Orthotic and Prosthetic Education and Research Foundation (OPERF)-which has already awarded several grants for research, according to Keith M. Smith, CO, LO, FAAOP, president of the American Academy of Orthotists and Prosthetists (the Academy)-the research base specific to orthotic intervention continues to grow steadily. Stroke survivors thus can look forward to more and better options in the years to come.
Miki Fairley is a contributing editor for The O&P EDGE and a freelance writer based in southwest Colorado. She can be contacted via e-mail at