2118 Motivation: Recovery Fuel
MEETING THE CHALLENGE OF RECOVERY
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Here is an actual conversation I had with a stroke survivor:
HER: Okay, Pete. You’ve been involved in stroke recovery research for a long time. What do you have that will help me recover use of my hand and help my walking?
ME: I have good news and bad news. The good news is that I have a plan that will help you get the most recovery possible.
HER: Great! I was hoping you’d say that!
ME: The bad news is that you’ll probably work harder than you’ve ever worked in your life.
HER: Oh. I was hoping you could come up with something where I didn’t have to work hard.
There the conversation died. She was unconvinced, and something I already knew was confirmed. The elephant in the room is that some stroke survivors don’t want to work hard toward recovery. At least this survivor was honest.
Is it possible to maintain motivation when the going gets (really) tough? This is no idle question. Although many claim to be willing to change their lives in profound ways, if the stakes are high enough, more often than not, people choose not to change. Consider the stroke survivor who has never been in good physical shape, has never been an athlete, and 212has never trained hard for physical gains. How is he going to magically transform into a “recovery machine?” How is he going to physically work harder than ever before?
Here are some thoughts about motivation:
• Maintaining motivation during the rigors of recovery is a discipline unto itself.
• It could not be simpler: People who stay motivated make progress.
• Motivation is essential to recovery, and if motivation is consistently maintained, it can drive recovery.
• Motivation is often the factor that has the most influence on recovery.
• Motivation is the core of recovery.
• Recovery from stroke is full of periods of incredible progress as well as disappointing lulls. Overcoming the slow periods and remaining focused is essential to the process of recovery.
People are motivated by a variety of different things. Here are a few quotes from stroke survivors regarding motivation:
• “I need to be independent. I don’t want to rely on my family.”
• “I have to get my hand and arm back. My weak arm has stopped me from things I love to do with my friends.”
• “I want to be able to take care of my children (or grandchildren or great-grandchildren).”
• “I can’t function with the constant fear of falling. I have to improve my balance and strengthen my legs.”
• “I see my recovery as an adventure. I want to know how far I can go.”
• “I don’t want to walk funny. It’s bad for business.”
Here are some key words that may help you determine what motivates you:
Important
Essential
Embarrassing
Promotes independence
213Sustains friendships
Allows childcare
Inspires fear
Saves (or helps you make) money
Makes you angry
A quick note about anger: In our society, anger is frowned upon, but anger is a powerful force that can be used to drive recovery. This is how Gandhi put it:
I have learned through bitter experience the one supreme lesson to conserve my anger, and as heat conserved is transmuted into energy, even so our anger controlled can be transmuted into a power which can move the world.
“Anger controlled” can be a powerful recovery tool.
Better Is Good
If you are willing to work hard, maybe harder than you’ve ever worked, you have the best chance of the highest possible level of recovery. Some survivors feel that the challenge of recovery is one of the defining moments in their lives. Accepting the challenges of recovery can make the difference between simply reclaiming something lost and embarking on a new adventure toward uncharted personal growth. Don’t give up; don’t give in. Recovery is full of ups and downs. Expect them to happen, and move on.
How Is It Done?
Motivation is tied to your personal aspirations, ambitions, and dreams. What motivates you toward recovery also depends on what you are unwilling to surrender. What you want to do and what you want back are powerful internal motivators. But if you do need inspiration from the outside, there are plenty of resources for that. Motivational stories can be found on the Internet, in books, movies, plays, and within one’s faith. Books and movies can offer suggestions, and they can provide an opportunity to “experience” someone else making mistakes and finding solutions. In a word, these stories can inspire. The books and movies you choose do not have to be stroke specific. They can be stories about athletes, mountain climbers, war heroes, or anyone’s story of survival and triumph.
214Here are some other ideas for remaining motivated:
• Recovery takes positive reinforcement. Celebrate the small successes.
• Turn recovery into a competition. Successful athletes always compete against themselves.
• Make recovery a social activity. Your success can be fostered with the help of others, even if they are not stroke survivors.
• Look for intensity of experience during recovery. The intensity of the experience will help ingrain what is being learned.
• Fall in love with the process of recovery.
• Have a recovery plan that includes measurable goals. Success should be measured.
• Make recovery efforts a part of your everyday schedule.
The challenge of recovery is at once tenuous, difficult, fraught with frustration, and full of fits and starts. But like a four-wheel-drive vehicle plowing through banks of snow, hard work can compensate for much of the difficult terrain. Researchers are just beginning to unravel the riddle of recovery. The secret seems to be obvious: Recovery takes a tremendous amount of hard and sometimes frustrating work. Hard work drives cardiovascular and muscular strengthening. Hard work goes into planning and stroke recovery research. Hard work powers through plateaus and forges the neuroplastic process.
What Precautions Should Be Taken?
The often uncharted territory involved in hard work requires the aid of a doctor and other healthcare professionals to make the journey toward recovery a safe one.
BE A CAVEMAN
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Nothing is forcing you to recover, and that just may be the problem. Archeologists make their living describing how our distant ancestors lived. They have found many skeletons of early humans with bone fractures, amputations, and skull trauma. Archeologists have also found evidence of arthritis, as well as an assortment of other injuries and illness. In many cases, these early humans survived their 215injuries. Human beings can have a stroke at any age. Many types of animals are known to have strokes. It can be assumed that these distant ancestors also had strokes. If a member of a tribal community had a stroke, his or her “therapy” would be ferocious. Survival of both the tribe and survivor would dictate their “caveman therapy.” Efforts toward recovery would focus on walking because these early humans were hunter-gatherers and they needed to move quickly in search of food. Stroke survivors would have had to learn to feed themselves or go hungry, toilet or get bacterial infections, and walk or get left behind. Sheer survival dictated the tremendous amount of energy they put into their recovery efforts. Their rehabilitation would flow organically from what they knew they had to do.
No doubt, their recovery from stroke would be physically demanding, but they would have been used to huge amounts of hard physical work. Every day of their prestroke lives was a struggle for food and against the elements and beasts. Walking long distances, hunting, hut building, tool making, rudimentary sewing, foraging, and so forth, would have made these humans tough beyond modern understanding. In that sense, stroke survivors today are at a disadvantage. We’ve gone soft. Are we able to channel the toughness that hides deep in our shared DNA?
Along with a physical toughness, these ancestors would have had another advantage: They were forced to recover. No other member of the tribe would be able to speak as loudly as the survivor’s own inner voice. “I want to survive.” The end result of this raging for recovery would be more recovery than similar stroke survivors experience today. Much of this concept is covered in research under the term, task-specific training. Research has found that:
• If you practice a movement, you might get better at that movement.
• If you practice that same movement as part of a real-world task, you can expect more recovery.
• If you practice the movement within a real-world environment that is important to you, you can expect even more return of movement.
• If you practice a task that is vital to you, you will get the most return of movement.
The more vital the task is, the more you will be driven toward recovery. Early humans would have viewed almost everything they did, every day of their lives, as vital. Their tasks were more than just important: They were essential to survival. Their bones whisper the secret of recovery: Work on recovery as if your life depends on it.
216How Is It Done?
Some stroke survivors use something close to this “caveman therapy.” People who obtain the best recovery from stroke tend to be people who have to get better. Their life goals dictate that they must recover. They challenge themselves in ways that other stroke survivors don’t. Driving their recovery are passions like independence, career, or essential hobbies like playing the piano, painting, or shooting pool. These modern-day “cavemen” and “cavewomen” are rare. They reclaim their passions because their lives depend on it.
The most effective clinical therapies mimic this recovery strategy. These therapies attempt to force recovery in one way or another. They are designed to cajole, prompt, and encourage, but they are, in the end, artificial. Researchers have been obsessed with designing artificial motivation. They try virtual reality, video gaming, and an assortment of other gizmos and tricks, but there is no substitute for that feeling from which recovery flows. What is it that you love? What in your life must you do? What do you have left to accomplish? Focus on these activities to unleash your inner caveman.
What Precautions Should Be Taken?
If skiing is your passion and you need to get back on your skis, don’t just strap them on and head for the mountain. Include your doctor, therapists, family, and friends in your plans, and train safely as you move toward your goal. You are not a caveman. Your responsibility to your own recovery requires that you stay safe.
WHEN HELP HURTS
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Life’s day-to-day challenges present opportunities to work on recovery. Think about the devices you use to improve your life. Consider reducing any form of assistance that is not essential to safety and/or independence. Doing so will open up a world of productive struggle.
Assistive devices (ADs) and the broader term, adaptive equipment, are names for rehabilitation gear that:
• Makes your life easier
• Makes you safer
• Helps you be more independent in your daily life
217Examples of these devices include:
• Specialized eating utensils
• Wheelchairs
• Reachers
• Leg lifters
• Zipper and button aids
• Writing aids
• Ambulatory aids (canes, walkers, etc.)
• Splints (ankle-foot orthoses, hand splints, etc.)
Assistive devices can promote independence, make your life easier, and make everyday living safer, but they may have a downside, too. These devices can make tasks that should be a challenge, easier. Doing without an AD can promote recovery. The challenge in everyday tasks is important to the process of recovery from stroke. It is worthwhile to weigh all the advantages of the AD, with special consideration regarding safety issues.
The typical medical model assumes that recovery from stroke is best served by making you safe, comfortable, and making life as easy as possible. “Treat ‘em and street ‘em” is often the mantra, and if “streeting ‘em” requires a few helpful ADs, well then why not? There are actually good reasons for thinking this way. The stroke survivor, his or her family, and the insurance company decide the speed at which survivors are pushed through the system. Simply, the goal is to get you as independent as possible in the shortest amount of time. Part of this effort involves providing the necessary AD to speed up the process, but there are points in the arc of recovery where you should question the need for individual ADs. Keep in mind that an AD can mask the fact that you can do without the device. With every AD you use, you are asked to do less and are discouraged from doing more. Attempting less generally means less recovery. An ongoing and thoughtful evaluation of the necessity of all ADs is wise.
Consider pens with a built-up barrel. These “fat pens” have been used by stroke survivors for the same reason small children use oversized pencils: The fatter a writing utensil, the easier it is to control. When you use an oversized pen, you require less finger control. This continual lack of challenge reduces the chance of ever gripping regular pens and pencils. Coordination and dexterity 218are challenged less. The fine-motor aspect of gripping is not challenged, so all the tasks that require the same sort of grasp will suffer. Larger utensils should be used temporarily as you progress toward more challenging grasping tasks, but many survivors use these aids for the rest of their lives.
If the AD does not impact safety, then eliminating it becomes a decision based on its relative necessity versus the therapeutic value of not using it.
Here are two other ADs that should be reconsidered:
• Hand splints immobilize the joint of the forearm, wrist, hand, and fingers. There is no proof that splints improve movement or reduce contracture. Splinting eliminates the use of muscles that control the splinted joints. Immobilizing joints in this way may reduce the amount of brain dedicated to those joints. This causes a sort of “bad neuroplasticity.” This reduces the amount of brainpower to those same joints, muscles, and movements that you’re trying to recover. Some splints, especially off-the-shelf splints, can actually damage the joints in the hand by forcing the hand into unnatural positions. This can cause small tears in the joints of the hand and fingers.
• An ankle-foot orthosis (AFO) stabilizes the ankle and raises the foot during walking when the leg is swinging forward. The AFO makes walking easier, but less is being required of the foot and leg. The foot is no longer being asked to lift (dorsiflex) at the ankle. Also, less is required in terms of coordination of the entire “bad” leg and foot. There are good reasons for using AFOs, including important safety issues. However, if your doctor agrees and if walking can be done safely, the extra effort may pay off in:
— Strengthening of the muscles that lift the foot
— Increased coordination during lifting the foot
— Strengthening of the muscles stabilizing the ankle
— A larger area of brain cells dedicated to the ankle (neuroplasticity)
— Increased ability to move the ankle
— More challenge toward normal coordination of the entire “bad” leg and foot
Note: Do not end the use of splinting or an AFO without the consent and sanction of your doctor. Ending use of an AFO can lead to falls.
219How Is It Done?
There are two broad ways to gradate the use of an assistive device (AD):
• Increasing or decreasing the time the device is used
• Increasing or decreasing the type of device, so there is more or less assistance
Some examples of gradation of dosage include:
• Choosing to begin to use the AD
• Increasing the amount of time that you use the AD
• Reducing the amount of time that you use the AD
• Ending the use of the AD
Some examples of gradation of type include:
• Examples of gradation of the amount of support used for walking
— A walker (a lot of support)
— Hemi-cane
— Quad cane
— Straight cane (a little support)
— No walking aid (no support)
• Examples of gradation of aids used to lift the foot and stabilize the ankle
— Ankle-foot orthosis
— Ankle brace or ankle stabilizer (e.g., Aircast)
— Flexible (e.g., Neoprene) ankle wrap
— High-top athletic shoes
— Shoes
— Walking barefoot
• Decreasing the size of a “build-up” (widening the circumference) on a writing or eating utensil
• Reducing the use of or eliminating elastic shoelaces, buttoning, and zipping aids
220This list represents just a few of a long and growing list of ADs used by stroke survivors. Occupational and physical therapists can provide a full list of available ADs.
What Precautions Should Be Taken?
The safety implications of ending your relationship with ADs can be enormous.
If the AD does impact safety, then a much more vigorous and thoughtful consideration must be taken. Ending usage of some ADs has the potential of putting the stroke survivor in danger. Consult with your doctor regarding ending use of any AD or splint. Do not end the use of splinting or an AFO without the consent and sanction of your doctor.
Also, it may be that you are not using an AD that you should be using. An AD can promote safety, independence, and/or promote recovery. New ADs are being developed and put on the market every day. ADs may provide efficiency and safety. They can also be an interim step on your road toward recovery. Some ADs have no downside and contain great benefits. For instance, grab-bars in the bathroom keep you safe in slippery areas, where challenging balance is dangerous.
RECONSIDER MEDICATIONS
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Rule One: DON’T EVER STOP TAKING MEDICATIONS OR CHANGE DOSAGES WITHOUT DISCUSSING IT WITH YOUR DOCTOR!
Rule Two: DON’T EVER STOP TAKING MEDICATIONS OR CHANGE DOSAGES WITHOUT DISCUSSING IT WITH YOUR DOCTOR!
Rule Three: SEE RULES ONE AND TWO.
Drugs affect your recovery. Drugs include all medications that are prescribed, over-the-counter, or in foods (e.g., caffeine). Drugs affect everyone physically, emotionally, and/or mentally. Stroke survivors have the extra burden of trying to figure out how their medications affect their recovery efforts.
Therapists have always viewed their patients’ medications as a mixed blessing. Consider antispasticity pills. They reduce spasticity, which helps make movement easier. Therapists like that movement is made easier, but 221these drugs are designed to relax all muscles. Because they affect all muscles, they tend to make patients tired. Tired patients cannot put their full mental and physical effort into their recovery. Pain pills, psychotropic medications (drugs that affect the mind), sleeping pills, and other drugs can have similar (tiring and/or unmotivating) results. Drugs can help or hurt your recovery. In fact, from one day to the next, the same medication may be a benefit and then a detriment. Consider narcotic pain medications. On Monday it may be too painful for you to move without the medication, so the drug is beneficial to recovery. On Tuesday you have little pain, but the medication has made you so tired that you can’t focus on your therapy.
Sometimes adding a new medication clearly helps recovery. A stroke survivor, here called “Tim,” has excruciating pain in his affected arm. Tim has what is called shoulder-hand syndrome. This is a form of reflex sympathetic dystrophy (RSD), a problem in up to 25 percent of stroke survivors. The arm is so painful that Tim can’t move it. Tim’s primary doctor suggests Tim see a physiatrist. The physiatrist correctly diagnoses his pain and gives Tim a new medication that dramatically decreases the pain. This means Tim can finally move his arm in relative comfort. Efforts toward recovery can then begin.
The decision of which drugs should and should not be used is best left between you and your doctor.
How Is It Done?
So how do you go about reconsidering medications? The best way is called the “brown bag medication review.” The idea is you throw all your medications in a brown paper bag.
In the bag should be . . .
• All prescription medicines (including pills and creams)
• All over-the-counter medicine taken regularly
• All vitamins and supplements
• All herbal medicines
All medications are placed on the counter in the exam room. The physician or pharmacist, with your help, decides which meds to keep, which to pitch, and which dosages to tweak. Some doctors estimate that if this review of meds is done, about 50 percent of the time the meds will, in some way, be wrong.
222During the brown bag review, the following is also provided:
• Tips for safe and effective medication use
• Answers to your questions about medications
Once the whole thing is figured out, you are given a card that has all the medication information on it. This information would be available for you to review, and for you to hand to doctors, dentists, and others who may need to know your medications at a glance.
What Precautions Should Be Taken?
Again, never discontinue medications or change dosages without discussing it thoroughly with your doctor!
THIS JUST GOT REAL: PSYCHOLOGICAL ADJUSTMENT AFTER STROKE
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What Is It?
Although not every survivor has psychological problems after stroke, many do. Sometimes those problems are
• Direct (because of the damage to the brain)
• Or indirect (because the stroke created such havoc in the survivor’s life)
• Or, most likely, both direct and indirect
Direct damage cause by the stroke: Damage to the brain causes psychological and emotional changes. Although the mechanisms are not well understood, stroke in one area of the brain can cause disturbances in many other, distant parts of the brain. For instance, a survivor may have a stroke on the outside of the brain (closer to the skull). However, that injury often affects deeper structures in the brain that control anxiety, depression, emotional swings, anger issues, and fatigue.
Indirect damage to your life: Stroke is not just traumatic to the brain—it is traumatic to your life! So, while the actual brain damage may or may not 223have a psychological effect, the stroke inevitably creates problems that can challenge the survivor psychologically. These challenges can include changes in employment, relationships, independence (and on and on). They can create emotional and mental problems that can, at certain points in the arc of recovery, seem insurmountable.
Because of all these emotional stressors, all these normal psychological and social responses to stroke may slow physical recovery.
How Is It Done?
There is much less research on psychological adjustment than there is on physical treatment. The trick is to find the combination of your own efforts and supportive assistance that works for you. Each person will have their own strengths to draw upon. And each community will have its own set of resources available.
Some powerful self-care practices to boost your recovery efforts are:
• Spending time with friends
• Meditation
• Music and/or singing
• Spirituality
• Artwork or visiting museums
• Stroke support groups or discussions with other stroke survivors
• Home exercise centering time
• Guided imagery
• Yoga and/or breathing practices
• Time in nature
• Gardening
• Relaxed play time with children
• Relaxed play time with animals
• Nourishing meals
• Water therapy (classes or baths!)
224Physiatrists (rehabilitation physicians) can support your efforts by referring you to:
• Physical therapists and physical therapy assistants can give you exercise routines that will be the most efficient use of your rehab energy and inspire you to keep exercising, which will improve your mood and increase your energy.
• Speech therapists can not only help you with improving your speech skills, but are also trained to assist cognitive rehabilitation, which can enhance your ability to plan and participate in your recovery program.
• Psychologists can help you form new patterns of thinking, and can educate you and your family about stroke issues and responses to life-changing events.
• Occupational therapists and occupational therapy assistants can help to improve quality of life by working with individual goals and skills for daily activities.
• Social workers help you to find the community resources that best suit your individual needs.
Precautions
Be sure to get enough rest. Make time to do what you love! Focused hard work is more satisfying and efficient if it is balanced by relaxation and fun. Be open with family and caregivers about any emotional issues that you’re dealing with.
Be careful with expectations. Survivors sometimes confuse letting go of rigid expectations with giving up. Lack of expectation can lead to lack of effort, but too much expectation can lead to increased anxiety, frustration, and/or depression. Doing your best (including setting up social support) is the best way to increase recovery success and satisfaction.
FIGHT FATIGUE
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Severe fatigue affects up to 70 percent of stroke survivors. Many survivors consider fatigue to be the worst symptom caused by the stroke. Post-stroke fatigue creates a downward spiral of disability. The more fatigue, the less effort is made toward cardiovascular and muscle strengthening. Decreased levels of 225exercise lead to weight gain, which leads to greater effort needed to move. This, in turn, leads to more fatigue, which leads to less exercise . . . and the spiral continues. Fatigue impacts many aspects of a stroke survivor’s life, not the least of which is recovery. It goes without saying that, if you are too tired to fully engage in your recovery effort, less progress will be made.
There are many reasons for fatigue after stroke, including:
• Rehabbing in places that are typically noisy (primary hospitals, rehab hospitals, skilled nursing facilities, etc.). This allows for less quality sleep. Sleep is essential to recovery. See the section Horizontal Rehab: Good Sleep = Good Recovery in Chapter 5 for more information on the importance of sleep to recovery, as well as strategies to get adequate sleep
• A lot of tiring effort toward recovery
• Everyday activities use about twice the energy than they did prior to the stroke
• Survivors have about half the cardiovascular (heart and lung) strength compared to prior to the stroke
• Survivors have about half the muscle strength on the affected side compared to prior to the stroke
• Stress from life after stroke saps energy and makes sleeping more difficult
• Prescribed medications often add to fatigue
In some stroke survivors, the following may also cause, or add to, fatigue:
• Pain
• Depression
• Living alone
• Living in an institution
• Having trouble speaking or understanding
How Is It Done?
Here are some ideas and strategies to increase energy after stroke:
• Get decent sleep. Strategies to sleep better after stroke can be found in the section entitled Horizontal Rehab: Good Sleep = Good Recovery in Chapter 5.
• As unbelievable as it may seem, exercise actually reduces fatigue, even in the short term. Yes, exercise fights fatigue!
• Increase your muscular strength. The more stored strength your muscles have, the less fatigue you will experience.
• Increase your cardiovascular strength. The more stored energy your heart and lungs have, the less fatigue you will experience.
• Meditate. Stress saps needed energy. Meditation can reduce stress.
• Reconsider your medications. Some medications reduce energy. These medications can include psychotropic (drugs that affect the mind) and spasticity medications. On the other hand, other medications are stimulants. These drugs increase energy, at least in the short term. (Warning: Do not ever stop taking medications or change dosages without discussing it with your doctor!)
• Proper nutrition can increase energy. Eating refined carbohydrates (white breads, pastries, rice, pasta, donuts, bagels candy, soda, etc.) can reduce energy. Fresh fruits and vegetables and lean protein choices can increase energy.
• Drink plenty of water. Dehydration saps energy. As people age, their sense of thirst decreases, so drink water even when you aren’t “dying of thirst.”
What Precautions Should Be Taken?
All of the suggestions for fighting fatigue should be done under the supervision of your doctor. There are many medical reasons for fatigue, from dehydration to diabetes, and from pain to depression. It is essential that the underlying cause of fatigue be determined.
WALKING YOUR WAY TO BETTER WALKING
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As obvious as it sounds, the best way of improving the quality of walking is to walk. The act of walking uses some of the most progressive concepts in recent rehabilitation research. For instance, one of the techniques researchers use to promote robust recovery is called task-specific training. This means training for recovery within the context of a valued task. There are few tasks more valued than walking. Walking also involves 227another buzz concept in rehab research: repetitive practice (the same movement is repeated). Researchers believe repetitive practice is essential to relearning a skill. Another cutting-edge concept in stroke rehabilitation is adding a rhythmic component. Walking is inherently rhythmic. Walking also involves another rehabilitation concept that researchers are keen on: bilateral training. Bilateral training involves having the two legs communicating with each other. Researchers believe that the two arms and two legs communicate with each other in two ways:
• The limbs communicate through the brain.
• The limbs communicate directly, right through the spinal cord, without the brain involved.
So walking brings together four advanced concepts:
• Task specificity: This involves practicing exactly what is to be learned.
• Repetitive: This involves doing the same movement over and over.
• Rhythmicity: This involves adding a beat. Walking itself supplies the beat.
• Bilateral training: This is where the two legs communicate directly. During bilateral training, the “good” limb can make the “bad” limb move better and faster.
Walking may just be the best exercise available. Walking:
• Is “low impact,” so it puts little stress on the joints
• “Banks” energy for the heart and lungs
• Burns calories and controls weight
• Controls blood sugar
• Increases mental agility
• Decreases the chance of blood clots in the legs, which reduces the risk of another stroke
• Builds muscle
• Improves balance and may decrease falls
• Increases bone strength
. . . and much more.
228How Is It Done?
There are a lot of ways to stay safe while pursuing an aggressive walking program. Proper orthotics, such as an ankle-foot orthosis (AFO), and appropriate walking aids, such as canes and walkers, can be discussed with your doctor and physical therapist. If, however, you are not yet ready to walk without support, there are still options (beyond wearing a gait belt and having therapists help you). All of the following are done under the care of a physical therapist:
• Treadmill training (TT): This can provide the safety and comfort of walking indoors with the added safety benefit of providing “endless parallel bars.” Treadmill training has inherent risks that can lead to falling. See the section Train Well on a Treadmill in Chapter 2 for full details on treadmill training.
• Partial weight-supported walking (PWSW)
— PWSW on a treadmill: You are partially supported by a harness. The harness can be raised to reduce the amount of weight you’re carrying. The harness can also be lowered so that you are carrying your full weight, but the harness catches you if you fall. This allows you to challenge your balance without risk of falls. The product usually associated with this type of training is called the LiteGait®.
— PWSW over ground: This system is the same as the treadmill version except you walk over flat ground. Products that fall into this category include the Biodex Unweighing System, the NeuroGym® Bungee Walker, and the LiteGait®. Contact a physical therapist or local rehabilitation hospital to find facilities in your area that provide PWSW.
• Researchers have found great results with a new kind of gait (walking) therapy. It is called speed-dependent treadmill training. It is a simple idea; your walking will get better and faster if you practice walking faster. When it comes to walking, speed is good. Research suggests that increased walking speed has a positive effect on attention, disability, mortality, future health status, confidence in balance, fear of falling, falls, where discharge will be, chance of hospitalization, and medical costs. Walking faster improves the quick movements needed to control balance, which translates into smoother and more efficient walking. Speed-dependent treadmill training has been used to double the walking speed of study participants.
229What Precautions Should Be Taken?
Walking is one of the most natural movements humans perform, but a walking regimen designed to improve the quality of gait takes more physical and mental effort than leisure walking. Because this type of walking regime is more intense than leisure walking, make sure to talk to your doctor and therapist prior to incorporating therapeutic walking into a total rehabilitation plan. If you are able to walk without aid, do so with safety in mind. Your doctor and therapist will provide the medical and physical limits that should be observed.
THE YOUNG ADULT STROKE SURVIVOR (YASS): DRIVEN TO RECOVER
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First, a question: What is a “young” adult stroke survivor (YASS)? Survivors can have their stroke at any time, even before birth (called an in utero stroke). A stroke early in life usually has a more profound imprint on the brain than a stroke later in life. The difference between an adult stroke and a stroke in children can be summed up in one word: architecture.
• Stroke in adulthood: A normal architecture, altered. Imagine building a new house. You build a good foundation, a solid frame, a strong roof, and so on. You put in the plumbing, electrical, and walls. Your new house is done. Then one day you have an accident! You back your car into the corner of the house. That part of the house needs to be fixed. The foundation is still there, the solid frame still exists in most of the house, the roof is still good; plumbing, wiring, everything is still good. You only need to fix that one room.
— A stroke in adulthood affects a normally developed brain. The size and location of the stroke determines what skills are lost.
• Stroke in childhood: An altered architecture. Now imagine your neighbor builds a house, but he’s not a very good builder. The foundation is uneven and the frame is crooked. Everything that is built around the foundation and frame is affected by the poor basic architecture of the building. To “fix” the house would require starting from scratch.
— A stroke in childhood affects how the brain develops. The brain in childhood is a blank slate. Neurons (nerve cells in the brain) haven’t “decided what they want to be when they grow up,” and whatever is imprinted 230on that blank slate affects the way the brain develops. Children have an immense amount of brain plasticity available to them. After stroke, children often do amazing things, given the amount of brain injury they have. There are classic examples of children who have a complete hemisphere (half of their brain) destroyed by stroke. In an adult, such a stroke would institutionalize the person for the rest of his or her life, but some children survive and thrive with half a brain. They are able to learn to read, write, have a sense of humor, be productive, and enjoy life. So it is unfair to describe the brain after a childhood stroke as having “poor architecture.” In fact, it could be considered “excellent architecture” given the amount of brain damage they have.
The impact of stroke before the brain is fully developed is much different than the impact of stroke after the brain is fully developed. The process of recovery in the two is very different as well. In fact, it is only in the adult brain that there is truly “recovery.” In childhood stroke becomes a part of development.
The purpose of this section, and, in fact, this book, is to aid in recovery. Therefore, the “young” end of the spectrum will be defined as “after the brain is fully developed.” But when is the brain fully developed? That is, when is someone biologically an adult? We know that the frontal lobes, responsible for impulse control, are not fully developed until around the 25th year. Bottom line: The young end of the spectrum is 25 years old.
The “old” end of the spectrum is also difficult to define. Somebody may be 50 years old, have had a stroke, and also have a number of other illnesses, as well. On the other hand, somebody may be 75 years old and have had no significant illnesses in their life except for the stroke. Typically, however, the upper age limit for a young adult stroke survivor (YASS) is 55 years old.
Definition of a YASS:
• A survivor of stroke between the ages of 25 and 55.
Some notable statistics about YASS:
• 15 percent to 20 percent of all strokes are in people under the age of 55.
• 30 percent of strokes are in people under the age of 65.
• The risk of stroke doubles for each decade after age 55, but the number of strokes is rapidly increasing in people between ages 15 and 34. It is believed that the increase is due to a rise in obesity and associated problems like diabetes, high blood pressure, and lipid disorders.
• Stroke is actually decreasing among older adults, but it is increasing among younger people. This trend has held steady since the mid-1990s.
How Is It Done?
YASS have many advantages over older survivors in the quest for recovery. It may be more easily understood like this: YASS don’t have many of the disadvantages that older survivors have.
YASS can work harder on recovery. They have the ability to put more effort into recovery, and effort is vitally important to recovery. Effort not only helps the heart, lungs, and muscles to get stronger, but effort drives changes in the brain.
There are other advantages young stroke survivors have. For instance, they . . .
• Have a better chance of surviving a stroke
• Are in better shape. Younger survivors naturally have stronger cardiovascular (heart and lung) and muscle strength
• Usually have fewer other diseases (besides the stroke) than older survivors
• Have more physical resources to draw from. This means that a deficit in one area can be overcome more easily in a younger stroke survivor than an older survivor
— Consider a vision problem sometimes seen after stroke: hemianopsia. Hemianopsia is a “visual field cut” where the stroke survivor can only see one side of his or her field of vision. The side the survivor can see is the same as the unaffected (good) side of the stroke. The side he or she can’t see is the “bad” side. In an older stroke survivor, it would be more difficult to compensate for this visual field cut. The younger survivor typically has better neck and trunk rotation. A younger survivor would be more able to swivel his or her head to compensate for the loss of vision
• Have a brain that is more able to “absorb the impact” of the stroke. Younger adults have less age-related thinning of the cortex (the outer shell of the brain where brain rewiring occurs). Also, the blood vessels in the brain of young survivors tend to be healthier. All of these factors lead to a greater potential for brain rewiring.
• Are usually highly motivated. The bigger proportion of their life is yet to be lived. Their aspirations give them a huge advantage in their drive toward recovery.
• Can “bounce back” after injuries. For example, if a younger person has a fall, they can be expected to recover from any injuries faster and more completely.
In terms of recovery options, there are no differences in what helps recovery in the young and old, but the core concepts of stroke recovery can be expanded in YASS. Consider the word “intensity.” That word is very popular in stroke rehab research. Intensity has to do with how much and how often a recovery option is used. Intensity is much like “dosage” in medication. The dosage has to do with how much and how often you take a medication. Generally, the more intensity (the higher the dosage), the better. YASS can do things that are more intensive because they have more energy.
Younger survivors have another advantage, as well: An easy acceptance of technology. Electrical stimulation, biofeedback, computer gaming, and so on, are technologies that can be very helpful at certain points in recovery. Younger stroke survivors may be more comfortable than older survivors with technologies that aid recovery.
Bottom line: What promotes recovery in both young and old is the same. However, younger survivors have more to put into recovery, and can expect more out of recovery. Age is one of the most important predictors of recovery after stroke. The closer you are to 25 years old, the better the recovery. More than 50 percent of young stroke survivors return to work. Young adult stroke survivors have much less of a chance to have a second stroke, as well. Approximately 33 percent of stroke survivors overall will have another stroke. In young adult survivors, the chance is much smaller—about 2 percent.
What Precautions Should Be Taken?
Many young stroke survivors are misdiagnosed when they first have their stroke. Many young people having a stroke are believed to be on illegal drugs. This is true even though the symptoms for stroke between the two groups 233(young and old) are similar. Part of this is because of the mistaken belief among medical professionals that stroke in young people is rare. However, while uncommon, stroke does happen in younger people. The misdiagnosis of stroke as a symptom of illegal drug use can delay time-sensitive treatment for younger survivors.
Young stroke survivors have more reason to modify risky behavior. Stopping smoking, for example, is more important to overall health to somebody who’s 25 years old than somebody who’s 95 years old.
While young survivors have more energy to put into recovery, the same precautions are just as important as with older survivors. Injuries hurt recovery. Always strive for recovery while also staying safe.234