Urgency Key But Perseverance Pays Off

Many high profile Americans have experienced stroke episodes—actors Kirk Douglas, Robert Guillaume, and Patricia Neal; entertainers Quincy Jones and Gene Kelly; Hugh Hefner; and writer Ray Bradbury. Quick medical intervention and rigorous rehabilitation helped these people and many more to return to their chosen professions.

For the 700,000 Americans who experience strokes each year, time is of the essence when it comes to treatment—so much so that health practitioners are now referring to strokes as "brain attacks" to emphasize the importance of getting medical help right away. Recent research has shown that quick intervention dramatically improves a patient's recovery.

But equally important in a stroke patient's recovery is early rehabilitation and a complete understanding of and commitment to the rehabilitation process. Ideally, this means working with a physical medicine and rehabilitation (PM&R) physician, also called a physiatrist, to design an individualized recovery program.

"Stroke recovery begins immediately and takes place over a long time—not just during a hospital stay or physical rehabilitation session," says Dr. Steven Flanagan, vice chairman, department of rehabilitation medicine at The Mount Sinai School of Medicine. "It is extremely important for people to begin as soon as possible and to then continue exercising beyond their rehabilitation stay."

After patients are treated for a stroke, their typical initial rehabilitation program will last 2-3 weeks depending on how severely the stroke disabled them. This program is critical to the patient's long-term recovery and well being.

A PM&R physician will evaluate not only the negative effects of the stroke but also the patient's pre-attack status taking into account their physical abilities, emotional state, family support, education and even spiritual resources. This in-depth personal understanding allows the PM&R physician to create a comprehensive recovery program with physical therapists, speech therapists, psychologists, and social workers.

"PM&R specialists provide the overview. Rehabilitation is a team sport—we're all working together, but overall I have the responsibility with the patient included first and foremost," says Dr. Charles E. Levy, system chief of physical medicine and rehabilitation services for the North Florida/South Georgia Veterans Health System. "But we can only help people who truly desire to help themselves—rehabilitation is an active partnership."

Flanagan stresses that every stroke patient is unique as is every brain attack and the resulting deficits that occur. Therefore every recovery is unique. Typically, after a PM&R physician evaluates a patient, the goal is to help clear as many of the obstacles as possible to his or her recovery so the patient can focus on returning to the daily activities that he or she is able to perform.

"Stroke happens. That's the bad news," says Levy who is also an associate professor in the department of orthopaedics and rehabilitation at the University of Florida College of Medicine. "The good news is there is great potential for the brain to recover from stroke. With diligent rehabilitation, those prospects generally get better."

Both specialists quickly point out that one of the most critical elements in a patient's rehabilitation from stroke is the strength and commitment of their primary support system—usually their family.

"Stroke often threatens our definition of ourselves by changing our ability to do things independently. Family is crucial in helping a person understand that they are not valued for what they do but who they are," explains Levy. "Because family members know the patient better than we ever can, we rely on them heavily. Their commitment often makes a world of difference in terms of recovery."

According to Levy, family members are particularly helpful when it comes to identifying the best ways to psychologically motivate the patient. Family members are also particularly adept at interpreting communications and signs when speech impairments are present.

Since the vast majority of people recovering from stroke will be cared for by family or loved ones, part of the rehabilitation program requires educating those caregivers on how to assist with necessary tasks, such as:

• Transfers - from bed to wheelchair, wheelchair to car, etc.

• Rehabilitation exercises - to strengthen weakened muscles

• Organizational strategies - such as laying clothes out in order

• Empowerment tips - such as verbal cues, a gentle inquiry rather than an order

• Food Preparation - because swallowing problems are common

Depression is more common in patients recovering from a stroke than other diseases with similar deficits, although it is not clear why this happens. When people get depressed their instinct is to do nothing. This can be very damaging to stroke recovery. Motivation and a positive attitude are key to obtaining an optimal level of recovery. "Obviously family are a great resource," reports Levy. "They can be especially helpful when it comes to recognizing depression and intervening early with proper medications if necessary."

Brighter Future

"This is a very exciting time for us—five to ten years ago the consensus was nothing could be done for stroke victims," says Levy. "Now we're making enormous strides in helping more and more people enjoy normal daily living." For example, one of the new treatments being investigated by PM&R physicians is constraint induced movement therapy where the arm from a patient's strong side is restrained for concentrated sessions of 8-16 hours over a period of two weeks. This forces the patient to use the weak arm and seems to help the brain reorganize damaged pathways to regain control over paralyzed limbs.