Post-stroke rehabilitation
involves physicians; rehabilitation nurses;
physical, occupational, recreational,
speech-language, and vocational therapists; and
mental health professionals.
Physicians have the primary
responsibility for managing and coordinating the
long-term care of stroke survivors, including
recommending which rehabilitation programs will
best address individual needs. Physicians are
also responsible for caring for the stroke
survivor's general health and providing guidance
aimed at preventing a second stroke, such as
controlling high blood pressure or diabetes and
eliminating risk factors such as cigarette
smoking, excessive weight, a high-cholesterol
diet, and high alcohol consumption.
Neurologists usually lead
acute-care stroke teams and direct patient care
during hospitalization. They sometimes remain in
charge of long-term rehabilitation. However,
physicians trained in other specialties often
assume responsibility after the acute stage has
passed, including physiatrists, who
specialize in physical medicine and
rehabilitation.
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Nurses specializing in
rehabilitation help survivors relearn how to
carry out the basic activities of daily living.
They also educate survivors about routine health
care, such as how to follow a medication
schedule, how to care for the skin, how to
manage transfers between a bed and a wheelchair,
and special needs for people with diabetes.
Rehabilitation nurses also work with survivors
to reduce risk factors that may lead to a second
stroke, and provide training for caregivers.
Nurses are closely involved
in helping stroke survivors manage personal care
issues, such as bathing and controlling
incontinence. Most stroke survivors regain their
ability to maintain continence, often with the
help of strategies learned during
rehabilitation. These strategies include
strengthening pelvic muscles through special
exercises and following a timed voiding
schedule. If problems with incontinence
continue, nurses can help caregivers learn to
insert and manage catheters and to take special
hygienic measures to prevent other
incontinence-related health problems from
developing.
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Physical therapists
specialize in treating disabilities related to
motor and sensory impairments. They are trained
in all aspects of anatomy and physiology related
to normal function, with an emphasis on
movement. They assess the stroke survivor's
strength, endurance, range of motion, gait
abnormalities, and sensory deficits to design
individualized rehabilitation programs aimed at
regaining control over motor functions.
Physical therapists help
survivors regain the use of stroke-impaired
limbs, teach compensatory strategies to reduce
the effect of remaining deficits, and establish
ongoing exercise programs to help people retain
their newly learned skills. Disabled people tend
to avoid using impaired limbs, a behavior called
learned non-use. However, the repetitive
use of impaired limbs encourages brain
plasticity and helps
reduce disabilities.
Strategies used by physical
therapists to encourage the use of impaired
limbs include selective sensory stimulation such
as tapping or stroking, active and passive
range-of-motion exercises, and temporary
restraint of healthy limbs while practicing
motor tasks. Some physical therapists may use a
new technology, transcutaneous electrical
nerve stimulation (TENS), that encourages
brain reorganization and recovery of function.
TENS involves using a small probe that generates
an electrical current to stimulate nerve
activity in stroke-impaired limbs.
In general, physical
therapy emphasizes practicing isolated
movements, repeatedly changing from one kind of
movement to another, and rehearsing complex
movements that require a great deal of
coordination and balance, such as walking up or
down stairs or moving safely between obstacles.
People too weak to bear their own weight can
still practice repetitive movements during
hydrotherapy (in which water provides sensory
stimulation as well as weight support) or while
being partially supported by a harness. A recent
trend in physical therapy emphasizes the
effectiveness of engaging in goal-directed
activities, such as playing games, to promote
coordination. Physical therapists frequently
employ selective sensory stimulation to
encourage use of impaired limbs and to help
survivors with neglect regain awareness of
stimuli on the neglected side of the body.
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Like physical therapists,
occupational therapists are concerned with
improving motor and sensory abilities. They help
survivors relearn skills needed for performing
self-directed activities-occupations-such as
personal grooming, preparing meals, and
housecleaning. Therapists can teach some
survivors how to adapt to driving and provide
on-road training. They often teach people to
divide a complex activity into its component
parts, practice each part, and then perform the
whole sequence of actions. This strategy can
improve coordination and may help people with
apraxia relearn how to carry out planned
actions.
Occupational therapists
also teach people how to develop compensatory
strategies and how to change elements of their
environment that limit activities of daily
living. For example, people with the use of only
one hand can substitute Velcro closures for
buttons on clothing. Occupational therapists
also help people make changes in their homes to
increase safety, remove barriers, and facilitate
physical functioning, such as installing grab
bars in bathrooms.
Recreational therapists
help people with a variety of disabilities to
develop and use their leisure time to enhance
their health, independence, and quality of life.
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Speech-language
pathologists help stroke survivors with aphasia
relearn how to use language or develop
alternative means of communication. They also
help people improve their ability to swallow,
and they work with patients to develop
problem-solving and social skills needed to cope
with the aftereffects of a stroke.
Many specialized
therapeutic techniques have been developed to
assist people with aphasia. Some forms of
short-term therapy can improve comprehension
rapidly. Intensive exercises such as repeating
the therapist's words, practicing following
directions, and doing reading or writing
exercises form the cornerstone of language
rehabilitation. Conversational coaching and
rehearsal, as well as the development of prompts
or cues to help people remember specific words,
are sometimes beneficial. Speech-language
pathologists also help stroke survivors develop
strategies for circumventing language
disabilities. These strategies can include the
use of symbol boards or sign language. Recent
advances in computer technology have spurred the
development of new types of equipment to enhance
communication.
Speech-language
pathologists use noninvasive imaging techniques
to study swallowing patterns of stroke survivors
and identify the exact source of their
impairment. Difficulties with swallowing have
many possible causes, including a delayed
swallowing reflex, an inability to manipulate
food with the tongue, or an inability to detect
food remaining lodged in the cheeks after
swallowing. When the cause has been pinpointed,
speech-language pathologists work with the
individual to devise strategies to overcome or
minimize the deficit. Sometimes, simply changing
body position and improving posture during
eating can bring about improvement. The texture
of foods can be modified to make swallowing
easier; for example, thin liquids, which often
cause choking, can be thickened. Changing eating
habits by taking small bites and chewing slowly
can also help alleviate dysphagia.
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Approximately one-fourth of
all strokes occur in people between the ages of
45 and 65. For most people in this age group,
returning to work is a major concern. Vocational
therapists perform many of the same functions
that ordinary career counselors do. They can
help people with residual disabilities identify
vocational strengths and develop resumés that
highlight those strengths. They also can help
identify potential employers, assist in specific
job searches, and provide referrals to stroke
vocational rehabilitation agencies.
Most important, vocational
therapists educate disabled individuals about
their rights and protections as defined by the
Americans with Disabilities Act of 1990. This
law requires employers to make "reasonable
accommodations" for disabled employees.
Vocational therapists frequently act as
mediators between employers and employees to
negotiate the provision of reasonable
accommodations in the workplace.
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