Rehabilitation after Stroke

Abstract

A 66-year-old man was suddenly unable to speak, follow directions, or move his right arm and leg. He received tissue plasminogen activator within 90 minutes. Four days later, his speech was limited to effortful answers of yes or no. He could not walk or use his right arm, and self-care tasks required maximal assistance. What advice would you offer him and his family regarding rehabilitation for his disabilities? THE CLINICAL PROBLEMApproximately 400 persons per 100,000 population over the age of 45 years have a first stroke each year in the United States, Europe, and Australia. Stroke is the most frequent cause of adult-onset disability among people in the United States, and the cost of related care is among the fastest-growing expenses for Medicare. 1 The likelihood of improvement after stroke varies with the nature and severity of the initial deficit. Approximately 35 percent of survivors with initial paralysis of the leg do not regain useful function, and 20 to 25 percent of all survivors are unable to walk without full physical assistance. 2 Six months after stroke, about 65 percent of patients cannot incorporate the affected hand into their usual activities. Poor upper-extremity outcomes are probable after a hemispheric infarction when the leg cannot move by two weeks and the hand has no movement or only slight finger flexion with no opening by four weeks, consistent with considerable damage to the corticospinal tract. 3 Patients who survive a stroke almost always have less physical disability by the end of the first three months. Functional scales, such as the Barthel Index and the Functional Independence Measure (which measure the physical assistance or supervision needed for self-care, including using the toilet, dressing, bathing, eating, and mobility), tend to show a plateau of gains by three to four months after stroke, partly owing to insensitivity of the scale to further improvements. Patients who no longer require assistance at that point may still be unable to use the affected hand, walk at speeds and distances that permit activities outside the home, or live alone. Only 25 percent of patients return to the level of everyday participation and physical functioning of community-matched persons who have not had a

Enhancing Rehabilitative Therapies with Vagus Nerve Stimulation

“…Physical rehabilitation is the most common post-troke intervention. Rehabilitation can yield some functional gains, but recovery is often incomplete and the majority of patients are left with chronic disability [52][53][54]. Motor networks in surviving peri-infarct regions, as well as the undamaged contralateral homotopic cortex and subcortical structures, demonstrate significant reorganization after stroke [55][56][57].…”

Intensive language training in the rehabilitation of chronic aphasia: Efficient training by laypersons

“…Cerebrovascular stroke is the most frequent cause of acquired disability in adulthood and among the fastest growing cost factors in the health system (Dobkin, 2005). As a consequence, much attention is devoted to effective rehabilitation strategies.…”

Global aphasia as a predictor of mortality in the acute phase of a first stroke

“…Global aphasia has also been shown to bring an unfavorable prognosis to post-stroke mobility recovery 16 ; this could be phylogenetically related to the simultaneous development of language networks and motor gesture activity in earlier primates 17 . On the other hand, former studies have shown that the nondominant hemisphere for language has a critical role in the recovery of aphasia, probably related to the lexical learning itself present in healthy subjects and to mechanisms of brain plasticity 3,11,18,19 ; recruitment of networks in the nondominant hemisphere is believed to occur concurrently with attempts to repair the damaged original language networks in aphasic patients 3,11,18 .…”

“…[1] A brief history of the acute symptoms had to be reported by the patient (whenever possible) or a relative, including data on cardiovascular risk factors and socialeducational information, along with a complete neurological exam and a succinct assessment for hearing impairment (listening to finger-scratching with closed eyes, in each ear at once) and visual acuity; [2] Patients were then tested for attentional deficits by means of the "A" Random Letter Test 7 , being required to tap the unimpaired hand on the desk immediately after hearing the letter "A" (75 letters were orally presented by the examiner, 20 of them were "A" letters); [3] Handedness was assessed according to a fivepoint scale of the Edinburgh Inventory 8 for performance in writing, tooth-brushing, catching food with a spoon, opening a box, drawing, using a knife without fork, sweeping the floor (upper hand on the broomstick), throwing a ball, holding scissors, and striking a match; [4] Visual perception was tested by showing the patients ten abstract figures in several levels of difficulty, each of them displayed for ten seconds, soon after which they would have to point to it among four other figures (scored as hit-or-miss) 9 ;…”