Rehabilitation services available in nursing facilities are more variable than those in inpatient units or outpatient. The highly skilled nursing facilities usually place greater emphasis on rehabilitation, whereas traditional homes emphasize residential care. Addition, there are fewer hours of therapy compared to those offered in rehabilitation units for inpatient and outpatient.

Home Rehabilitation Programs

Rehabilitation at home allows greater flexibility so that patients can design your own program of rehabilitation and follow an individual path. The stroke survivors can participate in an intensive level of therapy several hours per week or follow a less demanding. These arrangements are often the most convenient for people who do not have transportation or require treatment of a single type of rehabilitation therapist.

Patients who depend on Medicare for rehabilitation must meet Medicare’s requirements to be “homebound” or “homebound” to qualify for these services, but for now, the lack of transportation is not a valid reason to receive therapy at home. The major disadvantage of home rehabilitation programs is the lack of specialized equipment. However, performing the treatment at home gives people the advantage of practicing skills and developing compensatory strategies within their own environment.

Rehabilitation should begin as soon as the stroke patient is stabilized, often 24 to 48 hours after the stroke. This first stage of rehabilitation usually occurs in the acute care hospital. At the time of discharge from the hospital, the patient and his family, in coordination with hospital social workers, must find a suitable place to live patients. Many stroke survivors return home, while others move to some type of medical facility.

Rehabilitation units for patients hospitalized (inpatient)

Inpatient units can be independent or be part of larger hospital complexes. Patients usually remain in the installation of 2 to 3 weeks, and engage in an intensive and coordinated rehabilitation. Such programs often involve at least 3 hours of active therapy, 5 or 6 days a week. The inpatient facilities offer a full range of medical services, including the supervision of a doctor 24 hours a day, and access to a full range of therapists specializing in rehabilitation after a stroke.

Outpatient units

Often outpatient facilities are part of a larger hospital complex and provide access to doctors and a wide range of therapists specializing in rehabilitation after a stroke. Patients typically spend several hours, often 3 days a week at the facility participating in coordinated therapy sessions and return to their homes at night. The comprehensive facilities for outpatient treatment programs often offer as intensive as those of hospitalized patients, but may also offer less demanding regimens, depending on the patient’s physical ability.

Rehabilitation after a stroke of physicians, rehabilitation nurses, physical therapists, occupational, recreational, speech and language, and vocational, and mental health professionals.

Doctors

Physicians have the primary responsibility for management and coordination of long-term care of stroke survivors, including recommending rehabilitation programs that best suit the needs of each patient. Doctors also are responsible for the overall health care of a stroke survivor and advise you how to prevent a second stroke, for example, controlling high blood pressure or diabetes and eliminating risk factors such as smoking, excessive weight A diet high in cholesterol, and high consumption of alcohol.

Neurologists usually lead teams strokes intensive care and the care of patients while hospitalized. It is sometimes maintained by long-term rehabilitation. However, physicians who specialize in other fields often assume responsibility after the acute stage has passed, including physiatrists, who specialize in physical medicine and rehabilitation.

Rehabilitation nurses

Nurses specializing in rehabilitation help survivors relearn how to perform basic activities of daily living. They also educate survivors about the regular health care, for example, how to follow a medication schedule, how to care for your skin, how to move from bed to a wheelchair, and how to address the special needs of people with diabetes . Rehabilitation nurses also work with survivors to reduce the risk factors that may cause a second stroke, and provide training for caregivers.

Nurses are intimately involved in helping stroke survivors manage personal care such as bathing and 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 maintaining a strict schedule to go to the bathroom. If the problem with incontinence continue, nurses can teach caregivers of patients how to insert and manage catheters and to take special hygienic measures to prevent the development of other health problems associated with incontinence

Physical Therapists

Physical therapists specialize in treating disabilities related to motor and sensory problems. They are trained in all aspects of the anatomy and physiology associated with normal function, with emphasis on movement. They can evaluate the strength, endurance, range of motion, gait abnormalities, and sensory deficits to design individualized rehabilitation programs targeted for patients to regain control of 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 exercise programs to help people to retain the skills they have just retrieve. People with disabilities tend to avoid the use of damaged limbs, a behavior called learned non-use. However, the repetitive use of impaired limbs encourages brain plasticity 2 and helps to reduce disabilities.

Strategies used by physical therapists to promote the use of impaired limbs include selective sensory stimulation such as tapping or stroking, active exercises and passive range of motion, and the temporary restriction of healthy limbs while practicing motor tasks. Some physical therapists may use a new technology, transcutaneous electrical nerve stimulation (TENS acronym in English) that promotes brain reorganization and recovery of function. TENS involves using a small probe that generates an electrical current to stimulate nerve activity in the limbs damaged by the stroke.

In general, physical therapy emphasizes practicing isolated movements, repeatedly alternating between one and another kind of movement, and practicing complex movements that require a lot of coordination and balance, as up and down stairs or moving safely around obstacles. People who are too weak to bear their own weight can practice repetitive movements during hydrotherapy (in which water provides sensory stimulation while supporting the weight of the patient) or while they are supported by a harness. A recent trend in physical therapy highlights the effectiveness of activities with a goal, and games to promote coordination. Physical therapists often employ selective sensory stimulation to promote the use of impaired limbs and help survivors with unilateral neglect regain sensitivity to stimuli in the neglected side of the body.

Occupational and recreational therapists

As physical therapists, occupational therapists are concerned with improving motor skills. Help survivors to relearn motor skills necessary for self-directed activities – occupations or tasks – such as housecleaning, gardening, and arts and crafts. Therapists can teach some survivors how to adapt to manage and provide training on the road. I often teach people how to divide a complex into its components, each component practice, and then perform the entire sequence of actions. This strategy can improve coordination and can 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 those elements of their environment that limit the activities with a purpose. For example, people who have use of one hand can replace the buttons on their clothing with Velcro locks. Occupational therapists also help stroke survivors to use assistive devices such as canes, walkers, or wheelchairs. Finally, many occupational therapists teach people how to make changes in their homes for safer, 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 free time to improve their health, independence, and quality of life.

Speech and language

Speech pathologists, and speech help survivors with aphasia to relearn how to use language or develop alternative means of communication. They also help to improve their ability to swallow.

They have developed many specialized therapeutic techniques to help people with aphasia. Some forms of short-term therapy can improve the understanding quickly. Intense exercises such as repetition of the words of the therapist, practice following directions, and reading or writing exercises form the basis of language rehabilitation. Training and practice of conversation and the development of reminders or prompts to help people to remember specific words, are sometimes beneficial. Speech pathologists, and speech may also help stroke survivors develop strategies to circumvent the language disabilities. These strategies may include the use of tables of symbols or sign language. Recent advances in computer technology have spurred the development of new types of equipment to improve communication.

Speech pathologists, and speech using non-invasive techniques of imagery to study patterns of swallowing a stroke survivor and identify the exact source of their impairment. Difficulty swallowing can be caused by different reasons, including the swallowing reflex swallowing or delayed, the inability to manipulate the food with the tongue or the inability to detect the food is stored in the cheeks after swallowing. When you have determined the cause, speech pathologists and speech work with patients to devise strategies to overcome or minimize the deficit. Sometimes just changing the body position and posture correcting eating an improvement can be achieved. You can change the texture of foods to make them easier to swallow, for example, you can thicken thin liquids often cause a person to get stuck. Changing eating habits, for example, eating smaller portions and chew slowly, can also help relieve dysphagia.

Vocational therapists

Approximately one quarter of all strokes occur among people aged 45 to 65 years of age. For most people in this age, back to work is a major concern. Vocational therapists perform many of the same functions as regular vocational counselors. They can help people with residual disabilities identify vocational strengths and develop curricula vitae highlighting these strengths. They can also help identify potential employers, to find specific jobs and referrals to agencies providing vocational rehabilitation for people who have suffered a stroke.

The most important thing is that vocational therapists educate people with disabilities about their rights and protections they have under the Americans with Disabilities Act of 1990. This Act 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 at work.

Paralysis or problems controlling movement (motor control)

Paralysis is one of the most common disabilities resulting from stroke. The paralysis is usually only on the side of the body opposite the side of the brain damaged by stroke, and can affect the face, arm, leg, or an entire side of the body. This one-sided paralysis is called hemiplegia (weakness on one side is called hemiparesis). Stroke patients with hemiparesis or hemiplegia may have difficulty performing daily activities such as walking or grasping objects. Some patients experienced a stroke have difficulty swallowing, called dysphagia, due to damage to the brain that controls muscles to swallow. Damage to the bottom of the brain called the cerebellum may affect the body’s ability to coordinate movement, ie a disability called ataxia, leading to problems with posture, walking and balance.

Sensory disturbances including pain

Patients who have suffered a stroke may lose their ability to sense when the touch, or feel pain, temperature, or position. The lack of sensitivity may also hinder the ability of patients to recognize objects that support and can be so severe that the patient does not recognize his own limb. Some patients experience pain, numbness or tingling sensations or itching rare in the limbs paralyzed or weakened, what is known as paresthesia.

The stroke survivors often have a variety of chronic pain syndromes that result from damage induced by stroke nervous system (neuropathic pain). Patients with a severely weakened or paralyzed arm often feel a moderate to severe pain that extends from the shoulder out. More often, the pain results from the immobility of a joint or juncture due to the lack of movement and the tendons and ligaments around the joint is fixed in one position. Commonly, this is called a joint “frozen” movement “passive” articulation of the paralyzed limb is essential to prevent painful “freezing” and to allow the patient to move easily as long as voluntary motor strength returns . In some patients who have had a stroke, feeling pathways of the brain damaged, causing the transmission of false signals that result in sensations of pain in the limb or side of the body that has the sensory deficit. The most common of these syndromes of pain is called the “thalamic pain syndrome,” which can be difficult to treat even with medications.

Urinary loss contingency is quite common immediately after a stroke and often results from a combination of sensory and motor deficits. The Stroke survivors may lose their ability to feel the need to urinate or to control the muscles of the bladder. Others may lack the mobility to reach the toilet in time. There may also be a loss of bowel or fecal contingency or constipation. Permanent incontinence after a stroke is not common. However, even the temporary loss of control of bladder or bowel control can be emotionally difficult for stroke survivors.

Problems using and understanding language (aphasia)

At least one quarter of all stroke survivors suffer from some impairment in language that involves the ability to speak, write and understand spoken and written language. Damage induced by a stroke to any of the language control centers of the brain can impair verbal communication severely. Damage to the language center located on the dominant side of the brain known as Broca’s area, causes expressive aphasia. People with this type of aphasia have difficulty expressing their thoughts through words or in writing. They lose the ability to say the words they are thinking and to put words together in coherent and grammatically correct sentences. In comparison, the damage to a language center located in the back of the brain called Wernicke’s area, results in receptive aphasia. People with this condition have difficulty understanding spoken or written language and often have incoherent speech. Although they can form grammatically correct sentences, his speech often makes no sense. The most severe form of aphasia, global aphasia, is caused by extensive damage to several areas involved in language function. People with global aphasia lose nearly all their linguistic skills, they can not understand or use language to express thoughts. A less severe form of aphasia, called anomic or amnesic aphasia, occurs when there is only minimal brain damage, their effects are often mild. People with anomic aphasia may simply selectively forget interrelated groups of words, as the names of specific persons or classes of objects.

Problems with thinking and memory

Stroke can damage parts of the brain responsible for memory, learning, and discernment. The survivors of a stroke can be dramatically reduced or concentration may experience deficits in short-term memory. They may also lose their ability to plan, understand the meaning of things, learn new tasks, or engage in other complex mental activities. Two fairly common deficits resulting from stroke are anosognosia, an inability to accept the reality of the physical impairments resulting from stroke and unilateral neglect, ie, the loss of the ability to respond to objects or sensory stimulation one side of the body, usually the side damaged by stroke. The stroke survivors who develop apraxia lose their ability to plan the steps involved in a complex task to perform the steps in the proper sequence. Stroke survivors with apraxia may also have trouble following a series of instructions. It seems that apraxia is caused by a disruption in the subtle connections between thought and action.

Emotional disturbance

Many people who survive a stroke feel fear, anxiety, frustration, anger, sadness and a feeling of regret for his physical and mental deficiencies. These feelings are a natural response to psychological trauma of a stroke. Some emotional disturbances and personality changes are the result of the physical effects of brain damage. Clinical depression, a sense of desolation which breaks the person’s ability to function, emotional distress appears that stroke survivors feel more often. The signs of clinical depression include sleep disturbances, a change in eating patterns that can lead to a loss or sudden weight gain, lethargy, social withdrawal, irritability, fatigue, self-loathing, and suicidal thoughts. Depression after stroke can be treated with antidepressant medication and psychological therapy.

What is rehabilitation after a stroke?

Rehabilitation helps stroke survivors relearn skills lost when part of the brain is damaged. For example, these skills can include coordinating the movements of the legs to walk or run the steps involved in any complex activity. Rehabilitation also teaches survivors new ways of performing tasks to circumvent or compensate for any residual disability.

It may be that patients need to learn to bathe and dress with one hand, or to communicate effectively when their ability to use language has been affected. There is a strong consensus among rehabilitation experts that the most important element in any rehabilitation program is carefully targeted repetitive practice and targeted the same kind of repetitive practice that everyone makes when learning a new skill like playing the piano or throw a baseball.

Rehabilitative therapy begins in the intensive care section of the hospital after you have stabilized the patient’s medical condition, often 24 to 48 hours after stroke. The first steps involve promoting independent movement because many patients are paralyzed or seriously weakened. Patients are instructed to change positions frequently while they are lying in bed and passively or actively participate in exercises of power to increase their mobility and strengthen their stroke-impaired limbs. (Passive range exercises to increase mobility are those in which the therapist helps the patient to physically move a limb repeatedly, while exercises “assets” are made by the patient without physical assistance from the therapist.) Patients are progressing to sit alone, and change of bed to a chair, standing, holding his own weight and walk, with or without assistance.

The nurses and rehabilitation therapists help patients perform progressively more complex tasks and demanding, such as bathing, dressing and using the toilet, and encourage them to begin using their stroke-impaired limbs to perform these tasks. The first step in a return to functional independence of a stroke survivor is to begin to reacquire the ability to perform these basic activities of daily living.

You can identify some of the most important risk factors for stroke during a physical exam in the doctor’s office. If you are over 55 years, the worksheet included in this booklet can help you estimate your risk for stroke and show the benefit of controlling risk factors.

The worksheet was developed based on the renowned Framingham Study, sponsored by NINDS. Together with your doctor, you can develop a strategy to decrease the risk to normal or even below normal for their age.

You can control many risk factors for stroke, some with great success. Although the risk is zero at any age, if you start early and controlling your risk factors, you can reduce your risk of dying or becoming disabled because of a stroke. With good control, you can keep the risk of stroke in most age groups, below the one for accidental injury or death.

The Americans have shown that strokes can be prevented and treated. In recent years, a better understanding of the causes of stroke has helped Americans to make changes in lifestyle that have reduced by almost half the death rate from stroke.

More than a million stroke survivors suffer little or no long-term disability due to the attack. However, another two billion will live for the rest of their lives with limitations due to paralysis, loss of speech and poor memory. NINDS scientists predict that if they continue focusing attention on reducing the risks of stroke and using the now available therapies and developing new, Americans should be able to prevent 80 percent of all strokes.

A risk factor is a condition or behavior that occurs more frequently in those who have or may have increased risk of disease than in those without. Having a risk factor for stroke does not mean you have a stroke. On the other hand, not having a risk factor does not mean you will not have a stroke. However, your risk of stroke increases with the number and severity of the risk factors you have.

Strokes occur at any age in both sexes and all races in all countries. These may occur even before birth, when the fetus is still in the womb. In African Americans, stroke is more common and more lethal in young adults and middle-aged than in any other racial or ethnic group in the United States. Scientists continue to find more risk factors and more severe in some minority groups continue to search for similar patterns for stroke in these groups.

Some of the most important risk factors for stroke that can be addressed are:

High blood pressure.

Also called hypertension, is by far the most powerful risk factor. If your blood pressure is high, you and your doctor should create an individual strategy to lower the normal range. Some things that work are:

- Maintain a healthy weight.
- Avoid using drugs that are known to increase blood pressure.
- Reduce the use of salt.
- Eating fruits and vegetables to increase potassium in your diet.
- Do more exercise.

Your doctor may prescribe medicines that help reduce blood pressure. Controlling blood pressure will also help prevent heart disease, diabetes and kidney failure.

Cigarette smoking.

Cigarette smoking has been linked to the buildup of fatty substances in the carotid artery, the major artery in the neck that supplies blood to the brain. Blockage of this artery is the main cause of stroke in Americans. Nicotine also increases blood pressure, the carbon monoxide from smoking reduces the amount of oxygen the blood can carry to the brain, and cigarette smoke thickens the blood, making it more prone to clot. Your doctor can recommend programs and medications to help quit smoking. Quitting smoking at any age reduces your risk of lung and heart disease and several cancers including lung cancer.

Heart disease.

Common disorders of the heart such as coronary artery disease, valve defects, irregular heartbeat and enlargement of one of the chambers of the heart can result in blood clots that can dislodge and block blood vessels in the brain or that go to it. The most common disease of the blood vessels caused by fatty deposits in the arteries is called atherosclerosis. Your doctor will treat your heart disease and may also prescribe medications such as aspirin, which helps prevent blood clots. You may also recommend surgery to clear clogged neck artery if you have a particular risk profile. If you are over 50, NINDS scientists believe you should talk with your doctor to make a decision about aspirin therapy. The doctor can assess your risk factors and help you decide whether you would benefit from therapy with aspirin or another blood thinner.

The warning symptoms or a history of stroke.

If you have a TIA, get help immediately. Many communities are advised that those with signs of a stroke, call 911 for emergency medical assistance. If you have had a stroke in the past, it is very important to reduce the risk of a second attack. Your brain helps you recover from a stroke using substitutes body systems must now do double duty. This means that a second stroke can be twice as bad.

Diabetes

You may think this disorder affects only the body’s ability to use sugar, or glucose, but also causes destructive changes in the blood vessels throughout the body including the brain. Furthermore, if the levels of blood glucose are high at the time of the attack, usually the brain damage is more severe and extensive than when blood glucose is under control. Treating diabetes can delay the onset of complications that increase the risk of stroke.

The warning signs (or symptoms) are the signs your body sends that your brain is not receiving enough oxygen. If you observe one or more of the following symptoms of a stroke or stroke, do not wait, call your doctor or 911 immediately!

- Numbness, weakness or sudden paralysis of the face, arm or leg, especially on one side of the body.
- Sudden confusion, trouble speaking or understanding speech.
- Sudden trouble seeing in one or both eyes.
- Sudden trouble walking, dizziness, or loss of balance or coordination.
- Severe headaches, sudden and unknown cause.

Other warning signs that may occur include double vision, drowsiness and nausea or vomiting. Sometimes the warning signs last only a few minutes and then disappear. These brief episodes, known as transient ischemic attacks (TIA), sometimes called “mini-stroke.” Although brief, they identify a serious hidden condition that does not go without medical help. Unfortunately, as they disappear, many people ignore. Do not! Paying attention can save your life.

Stroke is the third leading cause of death in the United States. A stroke can be devastating for those affected and their families, robbing them of their independence. It is the most common cause of disability in adults. Each year more than 500,000 Americans have a stroke and about 145,000 die from causes related to it. The officers of the National Institute of Neurological Disorders and Stroke (NINDS) have committed to reduce that burden through biomedical research.

What is a Stroke?

Strokes or “brain attack,” occurs when blood circulation to the brain fails. Brain cells can die from decreased blood flow and consequent lack of oxygen. There are two broad categories of stroke: those caused by a blockage of blood flow and those caused by bleeding. While not usually fatal, a blockage of a blood vessel in the brain or neck, called an ischemic stroke, is the most common cause of a stroke and is responsible for approximately 80 percent of strokes. These blockages stem from three conditions: the formation of a clot in a blood vessel in the brain or neck, called thrombosis; the movement of a clot from another part of body and heart to the neck or brain known as embolism, or a narrowing severe an artery in the brain or leading to it, called stenosis. Bleeding in the brain or the spaces surrounding the brain causes the second type of stroke, called hemorrhagic stroke (commonly known as stroke).

There are two important steps you can take to reduce your risk of death or disability from stroke: know the warning signs of stroke and control risk factors. Scientific research conducted by the NINDS has identified warning signs and a large number of risk factors.

Blood delivers oxygen and nutrients to every cell and removes carbon dioxide and waste products produced by these cells.

This system is not easy to establish a clear separation between changes due to aging and the changes that are considered pathological phenomena. Cardiovascular injuries are very common, being the second most common cause of death after cancer.Types of cardiovascular disease

There are several types of cardiovascular disease:

- hypertension

- coronary heart disease (damage to blood vessels supplying the heart)

- Peripheral arterial disease (damage to blood vessels supplying the arms and legs)

- Deep vein thrombosis and pulmonary embolism

- congenital heart disease (heart defects present at birth)

- valvular heart disease (damage to heart valves)

- cerebrovascular diseases (thrombosis or stroke, injury to the vessels supplying the brain)

- rheumatic fever or rheumatic heart disease

According to the World Health Organization (WHO), cardiovascular disease causes 17.5 million deaths worldwide each year and account for half of all deaths in the United States and other developed countries.

Cardiovascular diseases are also a major cause of death in many developing countries.