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Neurosciences & Stroke

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Medical Impact of Stroke

A stroke has the potential to affect many areas of a person's functioning. To ensure rehabilitation is comprehensive, the rehabilitation treatment team addresses all the major functional areas. These include medical management, cognition, communication, behavior, mobility, self-care and the psychosocial aspects of care. WakeMed's stroke treatment protocols and the patient's plan of care are organized in this manner. These functional areas, and how a stroke can impact them, are described below.

Medical
Depending on the nature and severity of the stroke, there may be other medical issues resulting from the stroke that can impact recovery and the course of a patient's rehabilitation. Some individuals may have difficulty breathing initially, so a tracheotomy tube may need to be placed in the neck to help them breathe. Even when they recover the ability to breathe on their own, the tube may remain in place for a while longer to help clear secretions from the trachea. The ability to produce an audible voice is temporarily affected by the presence of this tube. During the course of rehab, a patient may have an objective study performed to ensure the least restrictive diet and prevent pneumonia. A Modified Barium Swallow Study (MBS) is performed in Radiology using fluoroscopy to observe the path of food and liquids as they enter the body. A Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is more commonly performed on the Rehab unit where a tiny camera is inserted in the nose to observe the food or liquids as well. Results of these studies will help the MD and SLP decide what diet is safest. Food may be chopped or pureed and liquids may be thin or thickened to different consistencies.

Many individuals with strokes have trouble swallowing safely (dysphagia). In some cases a feeding tube must be inserted through the nose to give liquid nutrition. When the swallowing problems are severe and likely to last a long time, a gastrostomy feeding tube (PEG) can be surgically placed in the stomach. This allows liquid nutrition to be given in large amounts several times a day instead of continuously dripped in, and is often more comfortable for the patient. Generally, this tube can be removed once swallowing improves.

When a brain is injured from any kind of neurological insult including strokes, it becomes more sensitive to developing seizures. Seizures are caused by abnormal electrical discharges in the brain. Symptoms may vary depending on the part of the brain that is affected, but seizures often cause unusual sensations, uncontrollable muscle spasms, and even loss of consciousness. Medications can be used to stop seizures and to prevent them from occurring.

Another problem commonly seen in individuals with strokes is spasticity. Spasticity is a condition in which muscles are continuously contracted. This abnormal increase in muscle tone results from a faulty signal from the brain to the muscles. The stiffness and tightness of the muscles may interfere with movement, speech, and the quality of walking. The degree of spasticity can vary from mild muscle stiffness to severe, painful, and uncontrollable muscle spasms. Treatment for this will depend on the particular individual’s circumstances, but could include such things as medications, and stretching exercises.

Cognition
Cognition is another word for thinking skills and includes such things as attention, memory, language, visual-spatial abilities, and executive skills. Cognition is frequently adversely affected by strokes. Cognitive changes with strokes are more likely seen with someone who has had a CVA on the right side of the brain.

Cognitive deficits can vary from mild to severe or profound, depending on the severity of the stroke and the stage of recovery a person is in. Cognition often shows improvement as recovery progresses. Also, some areas of cognition may be more impaired than others.

For example a person may have severe memory problems, but relatively intact visual perceptual skills. Individuals in the early stages of recovery from a stroke may have difficulty staying awake and alert. Sometimes, individuals with a stroke are awake and alert, but are very confused and restless and have a limited ability to understand the world around them. If the patient is functioning at this level of cognitive impairment, he or she may have problems with irritability, restlessness, poor attention, poor memory, difficulty solving everyday problems, and insight (difficulty understanding what changes have happened since the stroke).

Because of confusion and memory difficulties, the patient may “confabulate” or talk about things he or she thinks happened but which did not. As they improve and begin to understand what has happened patients often begin to participate more meaningfully in therapies and other activities. For example, the patient may be able to start to participate in dressing, feeding and bathing him or herself again, with assistance and guidance.

Some individuals with strokes will have less severe cognitive impairments, or will have more severe impairments in some areas of cognition, and mild or no impairment in others. Many patients who start with more severe cognitive deficits may show significant improvement, and eventually have less severe impairment in some or all areas of cognition. The patient may remember some things from day to day, and may be fully oriented (meaning they know who they are, where they are, and what date and time it is). The patient may be able to dress independently, and eat independently. However, some amount of supervision and assistance might be needed due to things like poor short-term memory, poor perceptual skills, or other cognitive deficits. The patient may not be able to see these cognitive problems and may try to do things the same way he or she did before the stroke.

In strokes of the least severity, or in patients with the highest recovery, cognitive deficits are subtle, and would not be noticed by people who did not know the person before the stroke. They may still include mild memory deficits, but also difficulties in planning and organizing their day-to-day functioning, particularly in complex activities like working or going to school. Rehabilitation efforts at this level are focused on teaching the patient strategies to help them in these areas.

Communication
Speaking, listening, reading, writing and gesturing are all ways we communicate. Having difficulty speaking and /or understanding words is called "aphasia" and this is usually associated with strokes on the left side of the brain. Patients with aphasia may have problems doing some or all of these things. Problems communicating can range from mild to profound depending on the nature and severity of the stroke. Individuals with the most severe strokes are unable to communicate at first. They may sometimes have their eyes open, and appear to be awake, but may not be able to speak or respond to you.

Some individuals can follow simple directions and may be able to talk using simple words or gestures (for example, the patient may point to a cup to tell you he or she wants something to drink), but may have difficulty finding the right words to say. Words said may not always make sense.

Patients may also experience "dysarthria" where weakness of the face, lips, tongue and larynx (Voice box) may cause speech to be "slurred" and unintelligible.

Apraxia can also be the result of a stroke. This is a motor planning disorder that can cause the patient to know what word they want to say but have difficulty planning the speech sounds. They may appear to be "searching" for a word with long delays in initiating speech.

Your speech pathologist will evaluate and recommend treatment for these communication and swallowing problems in Rehab. Generally as the patient improves, communication skills become more and more accurate.

Mobility
Mobility is about movement, whether it is going from laying down to sitting up, walking to the bathroom, or wheeling a wheelchair down the hall. In order to move the body, the brain must coordinate balance, strength and motor control.

Areas of function that can affect mobility in a person with a stroke are:

  • Balance – allows upright posture without falling over.
  • Strength– the amount of power that your muscles have.
  • Coordination– the smooth movement of multiple body parts in harmony.
  • Sensation – the body has several types of sensation, all of which are interpreted by the brain:
    • Hot/cold and sharp/dull
    • Deep pressure
  • Proprioception – tells the body where it is in space
  • Tone – an increased resistance to movement, a common problem in stroke patients, particularly troublesome if it overpowers available active movement. Tone can increase with laughing, coughing, sneezing, infection, fever or impaction. Tone is easily mistaken for active movement, but it is not under the patient’s control.
  • Range of Motion – Orthopaedic injuries, increased muscle tone, or changes in motor control can reduce the patient’s ability to maintain joint flexibility.
  • Posture – An individual’s ability to sit up or stand including head position is controlled by the brain. The stroke may also affect vision, perception, and motor control, all of which play a part in posture.
  • Motor Control – a combination of strength, balance, coordination and sensation to produce purposeful, controlled movement.
  • Motor Planning – the selection of the correct motor plan, including starting, continuing, and stopping a desired movement appropriately.

Mobility deficits in stroke patients are most commonly addressed by the physical therapist in Rehab. Here at WakeMed we use a variety of approaches to facilitate mobility, and we encourage the patient to use the affected side of the body as much as possible to retrain those muscles and pathways in the brain.