Physical Therapy Is Key for Stroke Recovery
Feb. 21, 2002 -- Stroke may cause serious physical and mental impairments, such asnear paralysis of one side of the body, difficulty understanding or finding words, slow thinking, and fatigue.
About 20 percent of initial survivors are unable to manage themselves in the first week or two and require inpatient rehabilitation.
The goal during this two- to five-week stay is to have them become independent enough in walking and self care to return home and then continue therapy as an outpatient for two to six months.
Remarkably, one-half of victims of a stroke have no weakness six months after the onset. However, many patients are still disabled.
About 20 percent cannot walk alone, 30 percent cannot carry out their daily self care without physical help, and two out of three can no longer socialize much.
Many studies of recovery convey a misconception about gains. They say that recovery only happens in the first three, or at most six, months after a stroke. This is true only if patients stop working at trying to improve the skills that are important to them.
Studies from our laboratory and others show the value of intensive practice at relearning a skill, even in the face of brain or spinal cord damage.
Regaining Upper Body Movement
Constraint-induced movement therapy requires that the patient try to use the affected hand and arm as much as possible to practice reaching and grasping items for two to eight hours a day for at least several weeks. There is no magic about this approach.
Patients must be able to voluntarily cock up the weak wrist at least 20 degrees and extend the fingers at least 10 degrees, meaning that they already have fair control of the hand.
If the hand cannot move or only clenches a bit, then this approach will not work. In general, the person who cannot extend the wrist and some fingers this much by a month after a stroke is not likely to get back much functional use of the hand.
However, many patients can practice and learn to extend the elbow and pinch the thumb against the second finger (key pinch) to use a very weak arm to assist themselves. This gain only comes from spending blocks of time daily in practice.
Regaining Lower Body Movement
For walking, treadmill training with partial body weight support helps some patients who cannot walk to partially recover.
Other people who can walk by themselves, but at a slow or tiring pace, can relearn to walk at faster speeds, so they can get about more naturally in the community.
This technique is really only a way to practice stepping faster, as fast as the treadmill belt is set. This is often beneficial since most patients do not feel safe when they practice walking outside at a speed that approaches normal walking speeds.
The key to this training is that the therapist provides hands-on and verbal cues to help make each step as normal and smooth as possible.
Overall Benefits
Proper practice leads to changes in how nerve cells in the brain come to represent the relearned movement. Undamaged cells and pathways spared from the stroke, and pathways that may ordinarily play only a minor role in carrying out reaching and grasping or stepping, come to be trained to assist the control of what is practiced.
The brain and spinal cord pay close attention to the details of that practice. They respond best to receiving sensation from the skin, muscles and joints that are similar to what the nervous system would have recognized as typical movements before the partial paralysis occurred.
This practice, then, may require the help of others, such as a physical and occupational therapist or a spouse, to assist the early attempts at movement. Further practice leads to more complete and speedier actions.
Practice also works for learning how to hold a spoon, to read when vision is partially lost to one side, and to speak or make gestures despite a loss or partial loss of speech.
Settle on what you want to practice, get some help in setting up the best conditions for practicing just a few activities for several hours a day, aim for small advances day by day, and concentrate on how and what you are doing.
No one ever learned to hit a tennis ball by practicing golf. You will improve only in the real-world activities that you choose and that you work hard to reacquire.
Dr. Bruce H. Dobkin is a professor of neurology in the Neurologic Rehabilitation and Research Program at the University of California, Los Angeles, School of Medicine.