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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