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HEART Insight:
doi: 10.1097/01.HEARTI.0000281887.73525.0e
Features: Recovery Room: After A Stroke, Then What?

How To Optimize Post‐Treatment Recovery

Papazian, Ruth

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New rehab techniques help restore quality of life

Astroke can change the way you walk, how high you can raise your arms, how well you can use your fingers or hold things and how quickly you can remember words, phrases and names. Rehabilitation therapists have a variety of tools and techniques to help overcome the damaging effects of a stroke, and improve quality of life.

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Walking The Walk

If you ask physical therapist Karen McCain, she'll tell you that learning to walk with a cane or a walker is not good enough—she won't be satisfied unless her patients can learn to walk normally without any assistance.

If you look at a stroke survivor who has learned to walk with the help of a cane or walker, you will notice the person will often take a very long step with the affected leg followed by a very short step with the good leg. This “limping” style of walking is impossible to correct, says McCain.

For this reason, she is heading a team of therapists at the Baylor Institute of Rehabilitation in Dallas, Tex., studying a rehabilitation technique called Locomotor Treadmill Training. A harness bears part of your weight as you walk on the machine. The stronger your legs become, the less you rely on the harness. Locomotor Treadmill Training has been used for several years, but McCain believes it is most effective if a patient starts rehab as soon as possible after the stroke, and can get off the treadmill and start walking on the ground in just a few therapy sessions—and that's what she has set out to prove.

In her study, 12 patients began therapy just days after their strokes. The 10 who completed the program all learned to walk normally again within two to three weeks. “You cannot tell from the way they walk that they have had a stroke. I do not believe traditional methods [using canes and walkers] can produce this result,” says McCain.

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A Helping Hand

Regaining range of motion in your arms and nimbleness in your fingers requires hours of repetitive rehabilitation exercises, some done under the watchful eye of the therapist and some done at home. Success depends on how diligently your “homework” is done every day. Two rehab techniques can help get around the tendency to slack off at home, when the therapist isn't around to prod you.

In Constraint-Induced Movement (C.I.) therapy you wear something that looks like an oven mitt on your good hand that prevents you from moving your fingers. With your affected hand and arm, you perform such exercises as turning dominoes over, moving glass marbles from one triangle on a Chinese checkerboard to another, and picking pennies out of a bowl that's also filled with kidney beans and transferring just the pennies to another bowl.

At home, the mitt forces you to use your weaker hand and arm when you brush your teeth, take off your shoes and socks, button and unbutton your shirt and comb your hair.

During the two-week period of intensive therapy, you're supposed to wear the mitt 90 percent of your waking hours—and a built-in timer will rat you out to the therapist if you don't!

Unlike conventional therapy, “we make the patient responsible for his own improvement,” says behavioral neuroscientist Edward Taub, Ph.D., a professor in the department of psychology at the University of Alabama at Birmingham. Taub, who developed C.I. therapy, added that making sure patients complied with their homework is another key component of its effectiveness.

After a stroke, it may be difficult—or impossible—to lift the affected arm at the shoulder, or to move the elbow, or to move your arm in one direction and then the other. With a conventional rehab program, a therapist will manually move your bad arm around to increase range of motion, or will strap the arm to a skateboard-like device and ask you to trace circles and other patterns on a tabletop.

The use of robotics has modernized hand and arm rehab. The robotic device does essentially the same thing as the skateboard, but is more like a video game. Instead of tracing patterns on a desk, you move a cursor on a video screen with the joystick-like grip at the end of a board to which your arm is strapped.

In a recent study, 30 patients whose arm movement was still restricted six months after their stroke were able to move and use the hand and arm that was affected much more easily after three weeks of robotics exercises. The study was among the first to focus on patients [who have severe impairment], and is “one of a number of studies that suggest these people can still benefit from physical therapy,” says Christopher Bever, M.D., Associate Chief of Staff for Research and Development at the VA Maryland Health Care System.

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Let's Talk

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Figure. A patient us...
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Neurolinguist Filip Loncke, Ph.D., is testing a bar-code reader called the B.A. Bar (pronounced like the name of that little elephant in those charming French children's stories) to help stroke survivors who have experienced speech loss (aphasia). The hand-held device pronounces words and phrases aloud when passed over the same type of barcode printed on product packages.

The barcodes can be attached to furniture, appliances and other items used every day, or to photos of people and places to help you recall or relearn words, names and phrases so they are at the tip of your tongue when you want to say something.

Right now, stroke patients read words off a written list to relearn them, but “our research shows that people...can remember, say and pronounce many more words and phrases [using the B.A. Bar],” says Loncke, an assistant professor at the University of Virginia's Communication Disorders Program.

“Learning is an active process. We learn very little by just hearing or seeing a word. We learn and retain more if we try to pronounce it,” he explains. And because the device pronounces a word or phrase exactly the same way each time—the same accent, the same vocal pitch—it's easier to remember.

Several hundred patients in Germany, France, Switzerland and several Asian countries have used the B.A. Bar, says Loncke. All five patients who used the machine on an experimental basis here in the U.S. were able to regain some vocabulary and became more willing to communicate with others, he said.

Loncke added that even before a patient's ability to talk improves, quality of life does. The B.A. Bar can be programmed to do the talking so, “It removes the barriers of being unable to say what you want to. For instance, in an emergency situation the machine can be programmed to ask for medical assistance.”

Intensive rehabilitation can help restore some of the abilities, function, range of motion and quality of life that were stolen by the stroke. But the most important factor determining how well someone does in rehab is his or her own motivation and determination.

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These Boots Were Made For Walking

The evening of March 14, 2006, Barbara Moore, 73, noticed her left foot “felt different” and that she “couldn't move it as much.” Around midnight, when she got up to go to the bathroom, she didn't realize at first that she had almost completely lost the use of the foot. She doesn't know how she got to the bathroom, but she does remember deciding to crawl back to bed so that she would not awaken her husband, Jim. “But I couldn't move at all.”

Her husband of 55 years heard her calling for help, picked her up off the floor, got her dressed and took her to the emergency room at Baylor University Medical Center in Dallas. “The first thing I thought when I got to the hospital was, ‘Where is rehab? I've got to get on my feet again.'”

At the hospital she learned about Karen McCain's study and enrolled within two weeks after the stroke. The only other therapy she received was on her left shoulder, to increase range of motion.

“You are put in a harness and lifted up until your feet barely touch the treadmill,” explains Mrs. Moore. With the affected foot and ankle braced, “you have to walk on the treadmill without holding on to the rail,” she adds. “You move your good foot by yourself, but a therapist has to move the affected foot for you. In about a week, maybe less, I was able to move both feet by myself.”

Each treadmill session lasted 10–15 minutes. Mrs. Moore also worked with the therapists to get in and out of a chair, and to stand on one foot while using the other to get on and off a step stool.

“After three weeks I could walk unassisted without a cane or a walker,” says Mrs. Moore. After a one-month stay at the Baylor Institute for Rehabilitation, “I went home and was able to do my housework.”

She remains active today. “We have stairs in our house, and I make sure to walk in the middle so I don't hold on to the rail or to the wall.” Most days, she also goes for a four-mile walk—and just to keep things exciting, “I jog a little bit during my walk.”

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Piano Man

Figure. Barbara Moor...
Figure. Barbara Moor...
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The day he had his stroke five years ago, Birmingham ophthalmologist Michael Bernstein had done seven surgeries and then went off to play his usual Friday afternoon game of tennis. “My partner said that I wasn't playing like I usually did, and I noticed that my balance was off and that my upper lip was slightly drooped on the left side.”

After he had driven back to his office to take care of a few errands, Bernstein found that he had to lift his left leg to get out of his car. Luckily, Bernstein's own physician was located in the same building.

The day after his stroke, Bernstein began physical, occupational and speech therapy. Physical therapy was basic—regaining some movement in the affected limbs. “I was told by the speech and occupational therapists that I would never tie my shoes again, or to practice ophthalmology again,” says Bernstein. “They were very negative.”

But on his neurologist's recommendation, he started Constraint-Induced Movement (C.I.) therapy a week after he was discharged from the rehab hospital. The therapy was intensive—8:40 a.m. to 5 p.m. five days a week for two weeks, plus he had to wear the mitt on the weekend.

“I was allowed to take the mitt off only in the bathroom, and to open the door of a car,” Bernstein recalls. “Try eating soup or Chinese food with your left hand,” says Bernstein, who was right-handed before his stroke. “I wore old clothes to therapy because at lunchtime, invariably you'd have food all over yourself.” By the second week, “I could play scrabble with my left hand,” says Bernstein.

After the two-weeks of C.I. therapy was completed, Bernstein resumed standard physical and occupational therapy, this time receiving electrical stimulation in the muscles of his left arm to strengthen them.

Bernstein celebrated his 60th birthday on January 20, 2007—and gave Taub a special treat: “Forty-two years ago, I was a good enough pianist to enter a competition to play with the Philadelphia Orchestra. I came in third, and never touched the piano again. But on my birthday, I put on a recital for about 30 people. Dr. Taub just about fell out of his chair.”

He proudly notes that his challenging repertoire included Sergei Rachmaninoff's Prelude in C Sharp minor; Ernesto Lecuona's Malagueña; and Chopin's Polonaise in A major, Op. 40. To get ready for his big day, he practiced the piano six days a week for 45 minutes to an hour.

Figure. Micheal Bern...
Figure. Micheal Bern...
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© 2007 American Heart Association, Inc.