Stroke, ‘an interruption of the flow of blood to the brain’

The primary goals of stroke management are to reduce brain injury and promote maximum patient recovery.

Rapid detection and appropriate emergency medical care are essential for optimizing health outcomes. When available, patients are admitted to an acute stroke unit for treatment. These units specialize in providing medical and surgical care aimed at stabilizing the patient’s medical status. Standardized assessments are also performed to aid in the development of an appropriate care plan. Current research suggests that stroke units may be effective in reducing in-hospital fatality rates and the length of hospital stays.

Once a patient is medically stable, the focus of their recovery shifts to rehabilitation. Some patients are transferred to in-patient rehabilitation programs, while others may be referred to out-patient services or home-based care. In-patient programs are usually facilitated by an interdisciplinary team that may include a physician, nurse, physical therapist, occupational therapist, speech and language pathologist, psychologist, and recreation therapist. The patient and their family/caregivers also play an integral role on this team. The primary goals of this sub-acute phase of recovery include preventing secondary health complications, minimizing impairments, and achieving functional goals that promote independence in activities of daily living.

In the later phases of stroke recovery, patients are encouraged to participate in secondary prevention programs for stroke. Follow-up is usually facilitated by the patient’s primary care provider.

The initial severity of impairments and individual characteristics, such as motivation, social support, and learning ability, are key predictors of stroke recovery outcomes. Responses to treatment and overall recovery of function are highly dependent on the individual.

History of stroke neuro-rehabilitation

Knowledge of stroke and the process of recovery after stroke has developed enormously in the late 20th century and early 21st century. It was not until the year 1620 that Johan Wepfer, by studying the brain of a pig, came up with the theory that stroke was caused by ‘an interruption of the flow of blood to the brain’. This was an important breakthrough, but once the cause of strokes was known, the question became how to treat patients with stroke.

For most of the last century, people were actually discouraged from being active after a stroke. Around the 1950s, this attitude changed, and health professionals began prescription of therapeutic exercises for stroke patient with good results. Still, a good outcome was considered to be achieving a level of independence in which patients are able to transfer from the bed to the wheelchair without assistance. This was still a fairly bleak outlook, but the situation was improving.

In the early 1950s, Twitchell began studying the pattern of recovery in stroke patients. He reported on 121 patients he had observed. He found that by four weeks, if there is some recovery of hand function, there is a 70% chance of making a full or good recovery. He reported that most recovery happens in the first three months, and only minor recovery occurs after six months. More recent research has demonstrated that significant improvement can be made years after the stroke.

Around the same time, Brunnstrom also described the process of recovery, and divided the process into seven stages.

1. Flaccidity (immediately after the onset); No “voluntary” movements on the affected side can be initiated
2. Spasticity appears, basic synergy patterns appear, minimal voluntary movements may be present
3. Patient gains voluntary control over synergies, increase in spasticity
4. Some movement patterns out of synergy are mastered (synergy patterns still predominate), decrease in spasticity
5. If progress continues, more complex movement combinations are learned as the basic synergies lose their dominance over motor acts, Further decrease in spasticity
6. Disappearance of spasticity, individual joint movements become possible and coordination approaches normal
7. Normal function is restored

(It must be remembered that although 7 stages mentioned – not all people progress from stage to stage – some may only get to stage 1 or others to stage 3 etc and their recovery may plateau)

As knowledge of the science of brain recovery improves, methods of intervening have evolved. There will be a continued fundamental shift in the processes used to facilitate stroke recovery.

Mental Practice/Mental Imagery

Mental practice of movements has been shown in many studies to be effective in promoting recovery of both arm and leg function after a stroke. It is often used by physical or occupational therapists in the rehab or home health setting, but can also be used as part of a patient’s independent home exercise program.

Mental Movement Therapy is one product available for assisting patients with guided mental imagery.

Current evidence indicates that most significant recovery gains will occur within the first 12 weeks following a stroke.