1295 Elements of Exercise Essential to Recovery
HORIZONTAL REHAB: GOOD SLEEP = GOOD RECOVERY
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One of the best things that you can do for your recovery is get enough sleep. Research in this area has been clear: Sleep helps recovery. Note that while enough sleep aids recovery, the opposite is true as well: Not enough sleep hurts recovery.
Studying how sleep affects recovery is simple. Researchers look at two groups of stroke survivors. One group gets plenty of sleep, and the other group has their sleep periodically disturbed. In both human and animal studies, the participants that get enough sleep recover more. Adequate sleep is beneficial to both mental and physical recovery. What you learn while you’re awake (and this includes learning movement) is imprinted into the brain while you’re sleeping. Sleep is not just a luxury; it is a vital part of recovery itself. Remember, stroke recovery requires motor learning. Motor learning, like any learning, involves making new connections between neurons in the brain. In this way, sleep is essential to moving better.
Stroke is brain damage. Brain damage caused by stroke can disrupt normal sleep cycles. Some survivors have found that periods of rest and/or regular naps can help. Some research has shown that naps actually lower the risk of dying of heart disease and stroke. The sleeping habits of humans were developed over hundreds of thousands of years of evolution. People are “programmed” to go to bed when the sun goes down and wake up as the sun rises. Artificial lighting, TVs, computers, and so on trick your brain into thinking it is daytime, even during the night. Going to bed at a set hour helps promote adequate sleep.
130How Is It Done?
General suggestions for promoting adequate sleep:
• Close the sleeping room door
• Put a sign on the door and inform everyone that you’re going to sleep
• Wear earplugs
• Use a “white noise” machine or fan to drown out outside noise
• Make the room dark. Light tricks the brain into believing it’s daytime, even if it’s 3 a.m. Turn off electronic devices. This includes TVs, computers, and so on. These devices, because they are lit, fool the brain into thinking that it’s daytime
• Lower the room temperature. The best room temperature is about 65°F (18°C). Warm air fools the brain into believing it’s daytime
• Physically (let it touch your skin) expose yourself to sunlight in the morning
• Be consistent with your schedule; get up and go to sleep at the same time every day
• Avoid electronic screens (TV, ebooks, phone) one to two hours before bedtime
• Exercise! Exercise promotes sleep
What Precautions Should Be Taken?
Sleep-aid drugs do not induce the same sort of learning benefit as natural sleep does. During natural sleep, the brain is very active. Natural sleep is when your brain consolidates new, important information while pitching unnecessary and redundant information. Natural sleep is active. Drugged sleep slows down brain activity.
Note that falling asleep, or dozing, during the daytime is actually an indicator for future strokes. People who fall asleep unintentionally have a four to five times greater risk of stroke than folks who don’t doze.
131GET A HOME EXERCISE PROGRAM
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Being able to depend on physical, occupational, and speech therapists for ongoing therapy is an ideal situation. Therapists provide experience, knowledge, guidance, and encouragement. Unfortunately, therapists, and the facilities where therapists work, are expensive. Insurance will only pay for a certain amount of therapy. So what’s a stroke survivor to do?
A home exercise program (HEP) is the group of exercises that the therapist gives you to do at home after all the therapy sessions are over. These exercises are usually given right before being discharged from therapy. The HEP may be provided before discharge from the hospital, again just before discharge from any skilled nursing facility, again during outpatient therapy, and then again at the end of any home therapy.
Therapists tend to leave the review of HEP until the final few visits, and the HEP usually is simply a rehash of the exercises done with the therapist during the course of therapy. Stroke survivors are handed a few photocopies of pictures or descriptions of exercises, and a review of those exercises is done. Here’s a little a joke for this process:
“What does HEP stand for?”
“Hand ‘Em Photocopies.”
There are two problems with looking at the HEP in this “last-minute” way.
1. (Before therapy has ended.) The HEP should be started much, much earlier. In fact, the HEP can start during the acute phase and continue for the entire journey toward recovery. The HEP is more than just a bunch of exercises. It is a series of responsibilities that the survivor has to his or her own recovery. See the section Expanding the Therapeutic Footprint in Chapter 6 for a list of responsibilities that could easily become part of the HEP.
2. (After therapy has ended.) Making a lifelong plan toward recovery is essential to maximizing potential. Therapist-developed HEPs tend to be rigid, reflecting only what is on the photocopied pages. This casual view is not only short-sighted, but it is actually detrimental to any further recovery. The traditional view of a HEP promotes the assumption that the stroke survivor won’t get any better. This is a built-in, self-fulfilling prophecy. The same exercises that . . .
• . . . were used in therapy
• . . . did not promote progress toward the end of therapy
• . . . did achieve plateau
• . . . triggered the end of therapies
• will, at best, retain the present level of strength, coordination, and ability.
The thinking is, “Since the clinicians have determined that the survivor won’t improve, they should keep doing the same thing to, at least, maintain the present level of recovery.” This is true from a purely statistical standpoint; most patients either do not progress or actually get worse after discharge from therapy. Because of this thinking, the typical HEP has no built-in points at which it should be updated and no flexibility to help promote progress toward recovery. Keep in mind this thinking was influenced much more by managed care (insurance) than any philosophy that therapists have. There was a day in the United States, not too long ago, when therapists could spend much more time with stroke survivors. This allowed for more time to develop treatment plans like the HEP. In rehabilitation, this changed with the 1997 Balanced Budget Act. What was specifically implemented was called the prospective payment system (PPS). The PPS affected payments for rehab services and affected how long survivors can be seen in the following settings:
Inpatient rehabilitation hospitals
Skilled nursing facility services
Home health services
Hospital outpatient services
Outpatient rehabilitation services
The HEP is rushed because the system rushes. In any case, the view that you want more out of your HEP will be an unusual view to most therapists, so you may have to coach them through the process. For instance, perhaps you are not walking upon discharge from all therapies. But after you are discharged, you start a new leg strengthening program that allows you to take a 133few steps. What do you do now? How do you build on this progress? How do you develop the cardiovascular stamina to walk farther? Which muscles should you stretch, and which should you strengthen to facilitate more walking?
Let therapists know that what is required is a strategy that will help you to continue to make gains. Ask them to build into a HEP the flexibility that will constantly provide higher goals, and ask therapists to provide the tools and strategies to achieve those goals. These requests are going to challenge therapists in ways that they are not usually challenged, and you may get some strange looks. But therapists are highly trained and highly skilled in developing plans that promote recovery. Remember, you are paying (and paying well) for therapy, and having them provide an adequate and challenging HEP is well within their job description.
Also, challenge your physiatrist and therapists with suggestions of techniques and technologies that you find during your research. If you see something that you think would work, ask them to follow through by explaining and implementing that therapy. You were most likely discharged because these health professionals believed that you have plateaued (not going to get any better). If therapists just continue to use the same techniques then, indeed, you will not get any better. Why? Because, the same techniques will probably continue to get the same results. In your own attempts toward recovery, look for new therapies that might work, and have doctors and therapists implement the therapies.
How Is It Done?
A HEP that includes effective therapeutic interventions and exercises is essential to ongoing recovery from stroke. Here are some suggestions when consulting with a therapist about the HEP:
• Start planning your HEP with your therapists as early as possible. Tell all therapists—from the hospital to home therapy—to provide the information and tools needed to continue progress at home.
• Let therapists know that you want a strategy that will help you continue to make significant gains, not retain existing levels of performance.
• Ask therapists to build flexibility into the HEP. The HEP should constantly provide higher goals, and ask therapists to give you tools and strategies to achieve those goals.
• Repeat these steps as time goes on. Every year or so (more, if it’s needed; less, if you continue to make great gains on your own) go back through the cycle of seeing the physiatrist and any appropriate therapists so that they can help you tweak your HEP. This will ensure that your at-home work continues to be challenging and fruitful.
The last week or so before ending therapies is way too late to work with therapists to develop a HEP. The HEP should be developed, in a rolling manner, from the beginning of your relationship with therapists. These professionals are trained to develop plans toward recovery. Much of their education is dedicated to the development of these sorts of plans. Many therapists end sessions because they are forced to, by pressure from managed care (insurance companies). Most will be happy that you want to continue to make progress once your relationship with them ends. But unless you prod and prompt therapists, and provide adequate time toward this goal, they will take the traditional perspective and wait until the last few days to “Hand ‘Em Photocopies.”
The best way to plan for a fruitful “rest of your life” after discharge is to make it clear to the occupational, physical, and speech therapists that you take your recovery very seriously, and you know that recovery will continue long after you’ve forgotten their names.
What Precautions Should Be Taken?
Much of the HEP will be implemented when the therapist is no longer around. This may add to the therapist’s reluctance to develop a HEP beyond what you’ve done in his or her care; the therapist doesn’t want to plan anything new that may put you into danger. Agree with him or her prior to the development of the HEP that you will take any safety precautions seriously, and you will inform your doctor as you progress. Any time you significantly alter your exercise or therapy routine, inform your doctor. The doctor will agree and encourage your ongoing efforts 99 percent of the time, but let the doctor make the final decision about the safety of the program.
As elements are added to the HEP, be sensitive to changes inherent in your body and mind. If you feel that something is hurting you or is too strenuous, stop. Generally, pain can be trusted as a warning of something harmful.
135SPACE TO RECOVER—THE HOME GYM
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Clearly, it’s easier to study at the library, do paperwork at your desk, and cook in the kitchen. Every stroke survivor also needs a space within his or her home dedicated to recovery. It should be a space where you can focus on recovering from your stroke. Like a library, it should only have the distractions you want; like a desk, it should be organized; like a kitchen, it should have all the recovery tools you need.
Some stroke survivors prefer to pursue at least some of their recovery effort in a community gym. Even if one joins a community gym (see the section Space to Focus—The Community Gym, later in this chapter), there are great reasons for having a home gym as well.
How Is It Done?
Your home gym can be a basement, an extra bedroom, or a corner of a room. It does not have to be big and does not have to have any more equipment than you need. It should have what is necessary to facilitate recovery. This may include exercise equipment, a TV, a stereo, a mirror, and inspirational art. Build your gym as a place of sanctuary and a place of work. Ideas for equipment include:
• A treadmill
• A recumbent cycle
• An upper body ergometer (hand cycle)
• An exercise mat
• Parallel bars or other equipment used to maintain balance
• Weights
• Resistance bands
• Electrical stimulation devices
• Balls, decks of cards, or other “toys”
This list can be as long or as short as it needs to be. A small amount of simple equipment that is well thought out and well used is better than a lot of expensive equipment left in a corner. Doctors and therapists can help compile a list of needed equipment.
136What Precautions Should Be Taken?
Be prudent when assembling the gym and think safety first. Any exercise or therapy equipment has inherent dangers. For instance, a treadmill provides a moving surface that may be inappropriate for some stroke survivors. Even something as simple as a ball can facilitate a loss of balance that can cause a fall. Consider installing grab-bars for any balance exercises you do. Make sure the floor is nonslip given the footwear you expect to use. Doctors will tell you if an exercise or therapy is safe, and therapists will explain how to do the exercise or therapy in the most effective way possible.
SPACE TO FOCUS—THE COMMUNITY GYM
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A community gym is a great place to focus on recovery. A well-equipped gym, with a supportive staff, provides the environment needed to build muscle, stamina, and flexibility. Gyms often have a pool. Pools provide the buoyancy and resistance of water to aid in recovery. Treadmills, weights, exercise balls, saunas, even giant mirrors, which provide valuable visual feedback, are usually available at the local gym. Gyms are motivating because motivated people go to them. Just being around other folks trying to reach their goals can be motivating.
Gyms in your community are not equipped the same as a home gym. Your home gym will have equipment that is specific to your recovery. For instance, your home gym might have an e-stim machine, a pegboard, or a deck of cards—all essential to your recovery, but not available at any gym. The role that the community gym plays in your recovery is different from the role of your home gym. The community gym will be a place of “the big three” of exercise:
1. Cardiovascular training
2. Weight training
3. Stretching
(You might also do any or all of these at home, as well.)
These types of exercises are essential aspects of recovery in order to “bank” the energy needed for every other part of the recovery effort.
137Some stroke survivors actually get in better shape after their stroke than they were before their stroke. This may happen for several reasons, including:
• A new emphasis on staying in shape
• A new emphasis on diet
• More exercise
• More time available to exercise
For some stroke survivors, the gym experience is a central part of life after stroke. Gyms can be centers of social contact and relaxation, and exciting places if you are motivated. They can also help you focus if you are less than motivated. Gyms provide a great combination of assets to help on the road to recovery.
How Is It Done?
A gym that is appropriate for recovery from stroke will have:
• Appropriate gear
• Surroundings in which the stroke survivor feels comfortable and relaxed
• A knowledgeable and supportive staff
Personnel at gyms do not often have expertise about, or experience with, folks with disabilities. Differences in credentialing add to the confusion. You should know that:
• Athletic trainers have a bachelor’s degree in athletic training and are certified by the state in which they practice.
• Personal trainers need no education and no certification.
There are many stories of stroke survivors receiving the wrong advice from well-meaning gym employees. Have a physical and/or occupational therapist direct the rehab program. They don’t have to go to the gym with you. The physical and/or occupational therapist simply needs to know what equipment is available so they can set up a safe and effective program. Of course, it would be highly beneficial if the therapist could go to the gym to direct the first session!
138Try to find a gym that is close to where you live, and try to incorporate as much of the trip to the gym as possible into your lifestyle. That is, if you can find a gym that you can walk to, use the walking as part of your recovery. If you don’t have a gym that close, at least make it convenient to your home or place of work.
Finding a gym whose members reflect your age group and gender will help you feel comfortable. Before joining a gym, tour the facility during the time that you would usually go. This will help determine the makeup of the membership and will help determine how crowded it might be during the time that you would typically go. Try to find a gym that offers classes that may facilitate stroke recovery. While spinning or rock climbing may not be within your interest and capacity, yoga, Tai Chi, or water aerobics may fit your ability and goals. Accessibility may be an issue as well. It is the law (within the Americans with Disabilities Act or ADA) that businesses must provide wheelchair-accessible entrances, exits, and bathrooms. This may not be the case, however. Most gyms make the effort to comply. But some of the equipment may not be accessible for folks with an inability to walk or transfer (i.e., get on/off equipment). For instance, a hydraulic lift chair is can safely transfer folks with mobility problems in and out of a pool. But many pools do not have one, so consider this when choosing a gym.
Your insurance may be willing to pay for some or all of your gym membership. In the United States, there is a way to get a free membership to thousands of exercise facilities across the country. It’s called SilverSneakers. Typically you have to be 65 or over to qualify, but if you’ve had a stroke and have disability benefits, you also may qualify. Find out more at silversneakers.com.
What Precautions Should Be Taken?
Inform your doctor before starting or changing any exercise program.
WEIGHT UP!
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Resistance training is the general term for any exercise in which muscles work against resistance. The most common type of resistance training is weight training (sometimes called weight lifting). Resistance training provides many important benefits to a poststroke therapy routine. Taken in total, these benefits make resistance training essential in any serious efforts toward recovery from stroke.
139Resistance training and weight training are sometimes used interchangeably. For clarification, here are the distinctions:
• Resistance training: Resistance training is pushing (or pulling) against an opposing force. This includes your own resistance (e.g., pushing one hand against the other), someone else’s resistance, gravity, resistance bands (made from sheets of rubber or rubber tubing), and so on.
• Weight training: Weight training is resistance training where the force against which you are pushing (or pulling) is weights, which include barbells, dumbbells, and weight machines (like those found in a gym).
This chapter uses the more catch-all term, resistance training. Here is a list of reasons to add this sort of training to your daily routine:
Resistance training:
• Increases strength on the “good” and “bad” sides
• Improves mobility (walking, wheelchair movement, etc.)
• Reverses muscle atrophy (muscles getting smaller and weaker). Atrophy affects both the affected and unaffected sides after stroke.
• Increases functional ability. (“Functional” is a buzz word used by healthcare workers that describes the ability to do normal, everyday activities, also known as ADLs or activities of daily living.)
• Increases strength, which helps all other efforts toward recovery
• Boosts chemicals (most importantly, BDNF) in the brain that can facilitate the neuroplastic change needed to learn and relearn movement
• Increases balance and decreases falls
• Increases cogitative function; its good for the brain
Bone density is an important benefit of weight training because the denser the bone, the stronger it is. There is a process that happens in bones called Wolf’s law. Wolf’s law says that a bone will get thicker and stronger because of the stresses that are put on it. As muscle pulls on bone, the bone responds by getting thicker and stronger. Over time, the more stress on the bone by the muscles, the greater the bone growth. Resistance training increases stress on bones, which increases bone density.
140Wolf’s law works in the opposite way, as well. The less stress that is put on bones, the weaker bones get. After stroke, the muscles on the weak side contract (tighten) less. Thus, the muscles on the affected side put less stress on bones. This lack of stress results in a decrease in bone strength. Because survivors tend to fall toward the “bad” side (the side that has weaker bones), they are at a much greater risk of fracture. Increasing bone strength on the “bad” side with resistance training reduces the chance of fracture.
There are other benefits to resistance training that are not specific to stroke survivors but are important to everyone’s health. Resistance training:
• Helps to balance blood sugar, which is important for diabetics and pre-diabetics.*
• Increases resting metabolism, which reduces weight or reduces the speed at which weight is gained.*
• Reduces blood pressure.*
How Is It Done?
Resistance training helps with so many of the body’s systems that it is good for everyone. But for folks who have had a stroke, resistance training is doubly important. Incorporate resistance training into a stroke-recovery strategy and be prepared for increases in energy, muscle strength, and endurance.
When deciding where resistance training fits into your recovery plan, carefully consider what area of the body to focus on. The recovery plan should include resistance training for all four limbs as well as your trunk (the area from mid-chest to hips, including the back). But some muscle groups will receive more focus than others. For instance, if it has been determined that the ability to walk will benefit from resistance training of the muscles of the thigh, then that’s where more time and resistance training should be put. Accurately evaluating which muscles need work is the first step in developing your resistance training program. Therapists can help you determine which muscles need the most work. You can also help determine what muscles to work on using common sense and intuition. Generally speaking, stroke survivors have much less weakness in the flexor 141muscles than the extensor muscles. Flexor muscles are muscles that decrease joint angles. For instance, in the elbow, the flexor muscles bend the elbow. The extensor muscles straighten the elbow. The elbow well exemplifies the problem that stroke survivors typically have: They can bend the elbow pretty well, but cannot straighten the elbow. This is a case where resistance training would be better directed toward the extensor muscles than the flexors muscles. Focus on muscle groups (groups of muscles that work together) that are weakest. See the section Challenge Equals Recovery in Chapter 2, for strategies to focus on what is hardest. This is not to say that the stronger of the two muscle groups, the flexors, should not be worked, as well. Despite the fact that the flexor muscles tend to overpower, both sets of muscles are weak after stroke. However, resistance training should be directed primarily toward the extensor muscles, which tends to be the weaker after stroke.
It is not necessary to buy expensive equipment to add resistance training to your recovery effort. The following work just as well as expensive weights or weight machines:
• Elastic bands or cords
• The force of your own body against itself (isometric exercise, e.g., grasping the fingers of one hand with the other hand and pulling both hands away from each other)
• The force of gravity (e.g., squats, heel-ups, press-ups)
When deciding how to incorporate resistance training into a recovery plan, keep in mind the following:
• Consult your doctor and therapist. They will help you determine the exercises that should be done, the progression of those exercises, and the equipment needed.
• Proper progression of exercises, to keep muscles challenged while maintaining safety, is an essential part of resistance training. Progression of resistance training should involve, over an arc of time, an increase in the number of repetitions, an increase of resistance (weight), or both.
What Precautions Should Be Taken?
Start resistance training slowly and allow for a gradual progression. There is a phenomenon called “delayed-onset muscle soreness,” commonly known as DOMS. When DOMS does occur, muscular soreness is felt from a day to a 142few days after the resistance training. This is a good reason to start slowly and frequently evaluate how your muscles feel. Building muscle involves developing small tears in muscle fibers, so a small amount of muscular pain is to be expected. The muscle is “repaired” by coming back thicker and stronger.
Consult your doctor regarding any health risks that may occur because of resistance training. Your doctor will tell you how the medications you are taking may affect your body’s response to exercise. Have your occupational or physical therapist help you design a resistance training program that is safe, has built-in increases of challenges over time, and is appropriate to your particular deficits and personal goals. Take your blood pressure and pulse rate before, during, and after resistance training (see the section Five Tests You Should Do in Chapter 3). Some doctors may not want resistance training incorporated if the stroke survivor has had a hemorrhagic stroke (bleeding stroke), because of the risk of another stroke due to possible spikes in blood pressure during resistance training.
BANK ENERGY AND WATCH YOUR INVESTMENT GROW
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Cardiovascular (or cardiorespiratory) fitness refers to the ability of the heart, lungs, and blood vessels to supply oxygen to muscles during exercise. Stroke survivors face unique challenges when it comes to their cardiovascular fitness.
• Stroke survivors have half the amount of stamina as people who have not had a stroke and are . . .
— Age-matched
— Out-of-shape
— “Couch potatoes” (people who do not exercise)
• It takes stroke survivors twice the amount of energy to do daily activities (walking, dressing, eating, etc.).
In other words, stroke survivors have half the energy to do twice the work. So, there is less energy available and more energy needed. This is why cardiovascular exercises and weight training—muscle building—are so important. There is a reason why athletes start their season with physically demanding workouts. They are banking energy for the game itself. You should do the same. Basic forms of exercise provide the stamina that’s needed to pursue the other challenges of recovery.
143Exercise helps recovery in many other ways. In fact, exercise helps the brain rewire after stroke. Exercise helps get oxygen-rich blood to the brain, and the brain loves oxygen. The brain is 2 percent of total body weight, but consumes 20 percent of the total oxygen used by the body. Exercise increases blood circulation to your brain. The improved oxygen flow to the brain helps every kind of learning, including the relearning of movement after stroke. Exercise also increases the blood levels of BDNF. BDNF, explained in more detail in Neuroscience: Your New Best Friend in Chapter 1, has been called “miracle grow for the brain” because it makes learning (including learning to move after stroke) much easier. Exercise, both cardiovascular and resistance training, increases your access to BDNF. You can bank energy by following a challenging and safe cardiovascular exercise program. The strength of the heart, lungs, blood vessels, and muscles is the foundation on which every other effort toward recovery is built. It’s that simple. Strength of conviction and inner strength can be sky high, but if you don’t have energy, you are stopped before you begin. On the other hand, if you are willing to commit to being in shape, you are a long way on the path toward recovery. With energy in the bank, the sky is the limit.
How Is It Done?
Options for cardiovascular workouts are available for every level of ability and disability. From bed-bound exercises to high-level aerobic workouts, there are many options to work the heart and lungs, no matter what the level of recovery. Your physical or occupational therapist or athletic trainer can suggest machines and exercises that build stamina, allow for maximum gains, and keep you safe. Many of the machines that are used for cardio conditioning, include:
• Recumbent (reclining) bilateral trainers (see the discussion of cardiovascular machines in Chapter 9: Recovery Machines)
• Recumbent stationary bicycles
• Upper body exercisers
There are even treadmills for wheelchairs that build cardiovascular strength. Many of the options are low cost. For instance, portable stationary cycles for the lower and upper extremity are available at nominal cost. A company called Isokinetic has five models of pedal exercisers that are appropriate for arm or leg exercise. The cost is between $20 and $70 (www.isokineticsinc.com/category/pedal_exercisers).
144Many local hospitals and rehabilitation hospitals have “cardio gyms” for folks rehabilitating from a variety of conditions. These gyms are open to stroke survivors and are staffed with knowledgeable therapists who can help direct workouts. These gyms typically require a doctor’s prescription. Insurance companies are sometimes willing to pay for memberships to these gyms if your workouts are seen as necessary for recovery and/or overall health.
For stroke survivors who cannot yet walk, partial weight supported walking (PWSW) equipment can be used at home. For example, both the NeuroGym® Bungee Walker and the Biodex Unweighing System are available for home use (see Chapter 9: Recovery Machines).
What Precautions Should Be Taken?
Ask your physical or occupational therapist to review the many options available to develop cardiovascular strength. Many of these options can be used within your home. Involving your doctor and rehabilitation professional to guide you toward safe and effective cardiovascular strengthening options is essential.
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* Diabetes, obesity, and high blood pressure increase the risk of having a stroke.