Rehabilitation after a Stroke

What is stroke?

Stroke is a common medical term. It means a part of the brain is dead due to the loss of blood supply to that part of the brain [1].

Annually, more than 100,000 patients suffer from a stroke in the UK; that is around 1 stroke every 5 minutes [2]. In 2015, stroke was the fifth most common cause of death in men and the third most common cause of death in women in England [3]. Stroke causes more deaths in women than breast cancer in the UK annually [4]. Stroke is also the leading cause of disability in the UK [2]. Annually, around £1.7 billion is spent on stroke patients annually in England [2].

What are the types of stroke?

Stroke is of different types.

Ischaemic stroke: Ischaemic stroke occurs when the artery supplying the blood to the brain gets clogged and blocked. The blood does not reach to the brain tissue resulting in its death [1].

Ischaemic stroke is the most common type; with 4 out of 5 (80%) stroke cases occur due to ischemia [1]. The ischaemic stroke is further subdivided into different categories depending upon the level and cause of obstruction [5].

The most important types are:

Large artery atherosclerosis comprises 18% of ischaemic strokes [6]. It occurs due to the formation of a clot within a large artery. These type of ischaemic strokes damage a greater part of the brain and cause significant clinical deficits [5]. The common deficits include paralysis of one side of the body, difficulty in swallowing, ambulation, severe language problems, blindness, or behavioural changes.

Small artery occlusion is responsible for 17% of ischaemic strokes [6]. It occurs due to the blockage of small arteries within the deep areas of the brain. It is also called “lacunar stroke”. It is common in patients with long-term diabetes mellitus and hypertension [5]. The clinical deficits vary from one person to another and range from mild sensory problems to complete paralysis of one side of the body.

Cardioembolic stroke occurs in 25% of patients with ischaemic stroke [6]. These patients have a significant heart disease and clot forms in the heart. The clot then travels to the arteries and suddenly block them, eventually stopping the blood supply to the brain. This type of stroke often behaves like a large artery atherosclerosis [5].

Cryptogenic stroke is a type of ischaemic stroke when the cause of stroke could not be established despite vigorous investigations. About one-third of all the ischaemic strokes fall into this category [5].

Haemorrhagic stroke: This type of stroke occurs when the artery supplying the blood to the brain is ruptured and starts bleeding within the brain [1]. Haemorrhagic stroke is responsible for 20% of all stroke cases i.e. 1 out of every 5 stroke patients [1]

Subarachnoid haemorrhage is a type of haemorrhagic stroke. It occurs due to bleeding on the surface of the brain [2]. About 10% of persons with subarachnoid haemorrhage eventually die before reaching hospital [4].

Transient ischaemic attack (TIA): This is a ‘mini-stroke’. It occurs when the blood supply to the brain is temporarily interrupted and returns to normal within 24 hours without causing permanent damage [4]. The transient ischaemic attack is a warning sign of future stroke. 1 in 12 people suffer from a stroke within 7 days of having a TIA [6]

Childhood stroke: Although stroke is more common in older people, nevertheless, it is also found in children. Approximately 400 children suffer from stroke in UK each year [2]. 75% of all childhood strokes occur under 10 years of age and 33% of them are under a year old [2]. Bleeding within the brain is more common in children. About 50% of the childhood strokes are due to bleeding as compared to 20% of adult population [10].

What are the risk factors of stroke?

There are multiple risk factors of stroke. The more risk factors you have, the more chances of you having a stroke.

The most important of the risk factors are:

High blood pressure (hypertension) is an important risk factor for stroke, especially haemorrhagic stroke. A blood pressure at or above 140/90 millimetres of mercury (mmHg) is considered high [14]. About 9.5 million people in the UK are diagnosed with high blood pressure [12] and more than 50% of stroke patients have high blood pressure [13]. If you have hypertension, an appropriate treatment for hypertension will reduce the risk of stroke and heart diseases [2].

Diabetes mellitus is an independent risk factor for stroke. About 3.6 million people in the UK are diagnosed with diabetes mellitus [12]. Diabetes doubles the risk of stroke and it is estimated that about 16% of diabetic patients die due to stroke [15]. These persons also often have increased blood pressure and blood cholesterol, compounding the risk of stroke.

High blood cholesterol level increases the risk of stroke. Large amounts of blood cholesterol builds up within walls of blood vessels and cause blood clots. These blood clots dislodge and move to the small arteries within the brain and block them, resulting in ischaemic stroke [16]. A 1mmol/L decrease in blood cholesterol reduces the risk of stroke by 21% [17]

Atrial fibrillation (AF) is an irregular rhythm of the heart. It increases the risk of stroke by five-folds [18]. About 1.2 million people in the UK have AF [12]. When a heart pumps irregularly, the turbulence increases within the blood flow. This increased turbulence may result in formation of blood clot within the heart. This clot may move into the arteries supplying the brain and block them [19].

Obesity is associated with an increased prevalence of high blood pressure, diabetes, high cholesterol, heart diseases, and stroke. Obese people have a 64% more chance of having a stroke [20]. Obesity is commonly measured by a body mass index (BMI) in which height and weight are taken into account [21]. A 10% decrease in body weight is recommended in decreasing the risk of stroke and heart diseases.

Smoking damages your blood vessels. About 18% of adults in the UK are active smokers [22]. Smoking increases the blood pressure and elevates the risk of stroke by two-folds [23]. Both the number of cigarettes and the duration of cigarette smoking increase the risk of stroke [21]. Second-hand (passive) smoking and Shisha smoking is also equally harmful [8].

Brain aneurysms are dilated weak areas of the blood vessels within the brain. The aneurysms are more prone to rupture and bleed. Some persons are genetically susceptible to develop brain aneurysms while in others, the aneurysms are formed due to long-term uncontrolled high blood pressure [4].

 

 

Physical inactivity is another modifiable risk factor. About 28.5% of UK stroke patients were physically inactive [13]. Physical inactivity leads to overweight and obesity which in turn is associated with increased risk of stroke and heart diseases. American Heart Association recommends that at least 30 minutes of moderate-intensity aerobic activity should be performed at least 5 days per week [15]. Exercise enhances brain vessel health, increases blood flow to the brain, and reduce hypertension, diabetes, obesity, hyperlipidaemia, and other risk factors for stroke [24]. Moderate exercise can decrease your stroke risk by one-fourth [25].

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Things to Do in the Event of a Stroke

Everyone should be familiar with the F.A.S.T. test to recognize the most common signs of a stroke.

Face               Check their face. Is their face look uneven?

Arms              Can they lift both arms?

Speech          Is their speech slurred?

Time               Is critical. Call 999 right away [26].

  • There is a treatment for Stroke if you act FAST. Approximately 1.9 million neurons die every minute a stroke is untreated [27]. Make sure every second counts.
  • Note down the time of symptoms onset. If you reach hospital within 4.5 hours of symptoms, your doctor may prescribe a clot buster, called tissue plasminogen activator (tPA), for ischaemic stroke [26]. Only 4 out of 10 stroke patients reached hospital within 4.5 hours in the UK in 2015-16 [28].
  • Check for breathing and pulse. If they are absent, call for help, and start CPR (cardio-pulmonary resuscitation).
  • Lie the patient down, turn them towards their left, and slightly raise their head, while you are waiting for an ambulance.
  • Do not give medication, food, or drinks to a stroke patient. Firstly, they might not be able to swallow properly and the food material might end up in their lungs causing pneumonia. Secondly, medications (even aspirin!) may be harmful for them and affect the future treatment options.
  • Stay calm and composed. Remind yourself that you are doing your best to help. Reassure your loved one that the help is coming.
  • If the symptoms resolve quickly, still rush the patient to the hospital. It might be a transient ischaemic attack (TIA) or a “mini-stroke”. TIA has to be taken seriously and should be properly investigated [6].

Life after Stroke

Stroke is a life-changing event. It has undoubtedly an immense effect on you and your family. But remember, there is a life after stroke.

Returning to work

Returning to work is an important milestone for a person with stroke. On average, about half of the persons do return to work [29]. How long it takes a stroke person to return to work depends upon their disability, the type of work, and their emotional state.

Remember, returning to work does not always mean having the same job, same roles, and responsibilities. It may be modified to encompass a new you. There are a lot of available options. Occupational therapists are indispensable in helping you return to work early.

Driving

All the persons should stop driving immediately after a stroke at least for one month. Stroke affects you in multiple ways. It may affect your judgment, co-ordination, vision, reflexes, and may cause confusion between right and left. Some of these deficits are not apparently evident.

Your doctor will access your recovery and will give you clearance when seemed fit. About 30-66% of persons resume driving after a stroke [30]. Nowadays, multiple vehicle adaptations and motoring devices are available that make driving possible and more comfortable.

Sexual activity

People usually experience difficulty in resuming sexual activity after stroke. It is often due to psychological factors rather than a physical disability. Talk to your spouse and your doctor about it.

Hobbies and leisure activities

Resuming hobbies is encouraged. Hobbies take your mind off the situation and help you recover. There are a lot of options available, from reading and writing to gardening, to continue your hobbies and spend your leisure time in a meaningful way. The stroke does not have to stop you from doing anything that you love to do.

Stroke Recovery

Stroke causes greater disability than any other disease [31]. Most stroke patients improve within the first weeks after a stroke and the improvement continues for months and years, as our brain has an ability to slowly heal and rewire itself [32]. Still, more than half of the patients are left with some sort of permanent disability [31].

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Stroke Survivors

Every person responds differently to a stroke. It is estimated that after a stroke:

  • 10% (1 out of 10) persons recover completely.
  • 25% of people recover with mild disability.
  • 40% of people have moderate to severe disability.
  • 10% of people need a nursing home or other long-term care facility.
  • 15% of people die shortly. [33]

Caregivers

In the UK, approximately 20% of the stroke patients, that is every 1 out of 5, are cared for by family and friends [34]. Caring for a stroke patient may be overwhelming. If you are a caregiver, you also need to care for yourself and ask for help whenever needed. About 64% of caregivers find very hard to deal with the stroke of their loved one and 84% of caregivers experience frustration [35].

Acute care

Acute (inpatient) care setting provides the 24-hour medical service in a hospital setting. The patients with multiple health related issues and with new stroke are managed in this facility. Doctors belonging to different specialities will be available to manage your condition. Rehabilitation is started as soon as possible and is actively done daily for several hours.

Long-term care

Long-term care occurs in a nursing facility. If your loved one has suffered from a severe disability following the stroke or that requires complex medical needs (e.g. ventilator dependent care), a long-term care is needed [36]. It is an on-going process that lasts for months, years, or even the rest of the patient’s life. A nurse will be available round-the-clock to address the patient’s needs. The nurse will also keep the family informed and helps them to make decisions.

Outpatient care

Outpatient care occurs with regular visits to a doctor’s office and rehabilitation centers. These persons have medical issues in control, live in their homes, and undergo rehab two to three times per week.

Home health agencies

These agencies provide rehab services at home as needed. The stroke persons who live at home but cannot travel for the rehab are suitable candidates for this service.

What is a Stroke rehabilitation program?

After a stroke, you may have to modify or relearn your daily activities. A stroke rehabilitation program helps people with stroke to function at the highest possible level despite physical disabilities, to achieve independence, and improve the quality of life [37].

Your rehabilitation (also called rehab.) will start in the hospital within 48 hours after a stroke. At the time of discharge, you will be provided a comprehensive plan of care to continue rehabilitation and recovery at home. Remember, rehabilitation plan is different for every person. It depends upon your functional impairments and how severe they are.

Rehabilitation program generally includes multiple interventions and an organized well-integrated multidisciplinary team that is often composed of following members [37].

  • neurologist is an expert in brain disorders that include the prevention, treatment, and recovery of stroke. He or she will follow you for your medical issues, the treatment you have been given, will monitor recovery, and provide a comprehensive plan of care.
  • physical therapist (Elite Personal Trainer) teaches and performs exercises that helps in achieving maximum movement, physical mobility, ambulation, and regain of muscle strength. The elite personal trainer helps with standing, walking, flexibility, endurance, confidence, inspiration to perform costumed movements and exercise, maximising your body coordination through a tailored to your needs personal training programme, and keeping your balance.
  • An occupational therapist (OT) helps in relearning the skills to achieve utmost independence in activities of daily living such as bathing, dressing, tying your shoes, and toileting.
  • speech therapist helps the stroke people overcoming their speech and language issues. A speech therapist is also involved in treating the swallowing problems.
  • rehabilitation nurse co-ordinates the medical support needs of patients with stroke throughout their rehabilitation.
  • psychiatrist helps stroke survivors to deal with the emotional and psychological problems that may have emerged after the stroke. In the UK, about 35% of stroke patients, that is 1 out of 3, have a mood disorder including depression [38].
  • vocational rehabilitation counsellor evaluates and helps the stroke persons to secure a gainful employment and return to work. They also work as mediators between employers and employees to provide reasonable accommodations in the workplace.

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Patient and Family Education

About 85% of people with stroke believe that their loved ones do not understand stroke [39]. If you are a caregiver, your understanding of the stroke as well as your communications with the stroke patient are indispensable for the rehabilitation process.

Stroke Support Groups

Every 1 out of 4 stroke patients live alone [39]. No matter how brave you are, you need help in adjusting to your new life. Support groups help stroke patients and their caregivers by providing a common platform for sharing their experiences and information. They help make new friends, provide an encouraging atmosphere, and ease the isolation and depression.

How do the special exercises at rehab programs for stroke patients help in recovery?

Stroke is the most common cause of adult disability [40].  About two-thirds of persons with stroke leave hospital with a disability [2]. Physical exercise is considered a major intervention in preventing some of these permanent disabilities and promote better functional outcome.

A stroke rehabilitation center is a specialised place to help the stroke patients recover early. They provide a detailed stroke rehab program where specialised task-specific exercises for stroke patients are performed and taught.

You will also re-learn very basic skills, for example eating, bathing, writing, reading, and walking. If you or your loved one had a stroke, these exercises will help you recover, regain the muscle strength, and live an independent life.

The basic principle for these exercises is selecting the exercises that have a greater impact on your targeted weak muscles and the repetition. The repetition is very important for recovery because it helps your brain to rewire itself and forms new connections. As it is said, the more the better [41].

Walking speed and walking distance alone are improved in more than 50% of stroke patients with these specialised exercises. There are also significant improvements in performing activities of daily living, maintaining balance, social participation, and positive quality of life [42].

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Are the exercises same for all persons?

No. Every individual will have a different exercise plan. The different types of exercises and their level of hardness depend upon your physical impairments.

How much time is needed for successful rehab?

It is different for every person. One may stay in rehab from months to years depending on the severity of the stroke and associated disability [43].

Role of an Elite Personal trainer in Stroke Rehabilitation

Elite personal trainer is a fitness expert that works one-on-one with a patient to improve overall health and physical fitness [43]. An elite personal trainer should have advanced certifications and needs to be skilled enough to successfully work with a stroke patient [43] when their primary doctor or their neurologist has given them the clearance to move and exercise.

The rehabilitation team often focuses only on the affected body. An elite personal trainer in London, on the other hand, does not only work to restore your strength and function after a stroke, but he or she works on your whole body (according with your capabilities).

An elite personal trainer will come to your home and will provide you a finely customised exercise programme completely tailored to your individual needs. He or she will pay maximum attention to compensatory movements, posture, coordination, stretching, endurance, and strength while taking into account all the health and safety points related to rehabilitation after stroke.

There are multiple exercise options available for a stroke patient for early rehabilitation. There are different task specific exercises for arms, legs, core muscles, and the whole body. They can be performed while you are seated or standing. They can be performed by carrying weights or without weights. These can be performed using specialised devices or carrying your own body weight. All these will be best decided by your own elite personal trainer. It emphasises the importance of choosing the best personal trainer in London in your path to recovery.

You will find many personal trainers in London, UK but choosing the best personal trainer is a daunting task.

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Since you are already reading this article, it means you have successfully find the best elite personal trainer in London, Jazz Alessi.

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Choosing the right Stroke Rehabilitation program

If you are a stroke patient, you will use much of your time using rehabilitation services. There are different rehabilitation programs available. They differ from each other on the basis of their setting, range, and frequency of services [44].

Choosing the right programme is essential and have a substantial impact on your recovery.

In an inpatient rehabilitation programme, you will be given a room and stay overnight as the treatment continues, while in an outpatient rehabilitation program, you do not stay overnight and return back home after receiving the treatment.

If you have multiple health issues that need 24 hours medical attention, you may need a long term nursing care setting for your recovery.

If your health issues are in control, you may be discharged home with a detailed exercise, nutrition and lifestyle plan.

You can pursue this plan actively by paying outpatient visits to your doctor and rehabilitation centers.

If you are home bound, for example, living alone, traveling issues etc., or you prefer rehabilitation at home, you may use home health agencies and acquire the services of an elite personal trainer [44].

Along with your required medical needs and your convenience, you should choose a rehabilitation program or an elite personal trainer on the basis of their reputation, experience, availability, compassion, and care.

Always meet with the trainer before you make a decision.

Make sure you are leaving your loved ones in the hands of experienced and compassionated elite fitness professionals.

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