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Stroke Disease - Approaches to Rehabilitation

by PaTrisha Anne(more info)

listed in medical conditions, originally published in issue 88 - May 2003

Introduction

Britain's main killer today is heart disease, the forbearer of stroke. Surprisingly, it is Asian people, rather than Caucasians who more commonly suffer a fatal stroke. People of Afro-Caribbean origin are also at high risk, particularly as they suffer a first stroke at an earlier age than other races. However, stroke can affect anyone, of any age. IVM (intracranial vascular malformations, the abnormal tangles of blood vessels in the brain, are the most common cause of haemorrhagic strokes in young adults aged 15-40. Hundreds of people are diagnosed with IVM every year.

The effects of a stroke are numerous but will vary from person to person. The after effect of stroke depends on which area of the brain is injured. A stroke might affect any of the following:

  • Balance;
  • Bladder and bowel control;
  • Cognitive function (memory and judgement;
  • Communication skills;
  • Concentration;
  • Emotional reactions (inappropriate laughing or crying);
  • Energy levels;
  • Level of consciousness;
  • Movement of one side of the body;
  • Orientation in time and place;
  • Perception of how the brain interprets what is felt, heard, seen and smelt;
  • Personality profile – depression is common after stroke;
  • Aphasia (Dysphasia ) – the loss of verbal understanding or expression;
  • Swallowing and chewing;
  • Vision.

The heart is the most hardworking muscle in the body. This organ beats over 100,000 times a day to pump vital blood through the body's veins and to deliver oxygen to the rest of the body.

A recent audit of stroke services taken by the Royal College of Physicians showed that although 73% of hospitals claim to have a dedicated 'stroke unit', of the 100,000 people in England and Wales who have their first stroke, only one in four will receive treatment in a stroke unit. The figures don't tally by my calculations!

Furthermore, the report demonstrated that around 6,000 patients die each year from lack of treatment in a stroke unit. It was also found that only 27% of stroke patients actually spend just half of their hospital stay in a dedicated stroke unit. In 1999 this figure was just 25%, an increase of a mere 1% per year! Doing a quick calculation these figures equate to about 70 years before hospitalized stroke patients could spend half their post-stroke care within a devoted unit.[1]

Here's another calculation for you. Of the 100,00 people who suffer a stroke in the UK, the NHS will pay a mere total of 6% of hospital expenditure in re-habilitative therapy on the two thirds of patients who survive.

What is Stroke?

CVA, a cerebrovascular accident or stroke, occurs when the blood supply to part of the brain is cut off by a blood vessel that has either blocked or burst artery, resulting in the death of part of the brain tissue.

The brain is the nerve centre housing the nerves, which enable the human body to move, to speak, to see and to hear. When brain damage occurs, the brain cannot produce the necessary signals to coordinate thought processes and body movement. So, since most functions of the body are controlled by the opposite side of the brain, if a stroke occurs in the left side of the brain, functions on the right of the body will be affected.

Yet the brain is a remarkable natural computer. Natural healing occurs during the early post-stroke period, with recovery of mobility happening more quickly and to a higher quality than the recovery of arm and hand function.

Aneurysm

Strokes can be caused by a cerebral aneurysm, a dilation, or swelling of a blood vessel causing the wall of the artery to blow up like a balloon. when the aneurysm ruptures, a sub-arachnoid hemorrhage usually bleeds into the area surrounding the brain (sub-arachnoid space). An intracerebral haemorrhage, when the aneurysm ruptures and bleeds into the brain itself, is less common.

We all have a tendency to carry blood clots in our veins, but the average healthy human being does not suffer a stroke.

What causes aneurysms?

Hypertension (high blood pressure) and arteriosclerosis, the furring of the artery walls can cause an aneurysm to grow and rupture. So too can certain infections of the blood.

TIA or 'Mini Stroke'

Between 30,000 and 40,000 transient ischaemic attack s (TIAs), or 'mini strokes', occur each year in the UK alone, with approximately a quarter of those sufferers going on to have a full-blown stroke within a few years. Following a TIA, the risk of stroke increases to approximately seven times that of the general population of the same age. Up to 12% per cent of TIA victims will sustain a stroke within the following 12 months, with 7% per annum thereafter. The risk of death from an MI (myocardial infarction), or heart attack, is 5% per year.

The symptoms of TIA are very similar to a full stroke, with sudden weakness, numbness, clumsiness or pins and needles on one side of the body, a sudden loss of, or blurred sight in one or both eyes, slurred speech or difficulty finding words.

What Causes a TIA?

Two large blood vessels, called the carotid arteries ,one on either side of the neck, carry oxygenated blood up into the head where they branch into smaller and smaller blood vessels, in turn carrying blood to all parts of the brain. If one or more of these tiny blood vessels gets clogged, by a blood clot or other debris, the blood supply to nearby brain cells may be disrupted. If this disruption is temporary, a TIA may occur. If the disruption is permanent, it may result in a stroke.

Sometimes a TIA occurs when a blood clot from a blood vessel in another part of the body, or from the heart, moves upwards into one of the brain's arteries. Very rarely, symptoms of a TIA are due to bleeding (hemorrhage) in the brain or other causes rather than clogged arteries.

Stroke and its Legacy

Incontinence can rear its messy head after a stroke. Around 50% of all stroke survivors experience varying degrees of bladder control. Thankfully the symptoms are not critically permanent, although statistics do indicate that one fifth of stroke patients continue to experience bladder control after being discharged from hospital, so much so, that one in seven continue to a degree to be incontinent.

In some cases stroke damage may occur to the part of the brain that controls the bladder and/or the bowel. When this happens the patient will need to re-learn toileting skills, bearing in mind also that there are a number of other reasons why these skills may need to be re-learned. Mobility is the main culprit, including the loss of simple dressing and un-dressing skills. Then we have speech. Speech may be affected after the stroke, causing problems in communicating to the carer the need to visit the toilet. After all, toileting remains a taboo subject, particularly as people are even in this day and age embarrassed to voice the subject.

Case History

Betty and Stan recently celebrated their 50th wedding anniversary by taking their grown-up children and grandchildren on the Christmas holiday of a lifetime to the spectacular warm climes of Goa. Cases were packed, tickets and accommodation booked, time off work arranged and cameras loaded with film at the ready. Excitement was running high and spirits lifted. Christmas came and went. Everyone returned home tanned from the sun and rested from the bliss experienced in such a charmingly friendly and restful place.

Then tragedy struck. Betty suffered a heart attack. The cardiac surgeon recommended that a triple by-pass operation would add at least another ten years to Betty's life, which she could live out in a comparative pain free lifestyle. The alternative was to take the prescribed medication, go home and hope she would live another two to five years.

Human nature being what it is, Betty and Stan decided the triple by would be the better option, particularly as the cardiologist had indicated that if Betty were to continue to stay in hospital until the end of the month, only three weeks away she could be seen and operated on in a private capacity.

Feeling privileged and full of confidence in such a decision Betty agreed to spend the next three weeks waiting on the NHS.

The atmosphere was buoyant. During her sojourn, Betty made friends with several other heart by-pass patients, who also had the option to be treated privately from the NHS 'kitty'. Each and every one of them had high praise of their operations, of the heart specialist performing the surgery and of the after care. It all looked and sounded good.

At last Betty was given her date and arrangements were made to transport her and Stan up to London. Everything was going to plan.

That fateful day Betty underwent the surgeon's knife. Tubes and pipes were inserted into her body to keep her alive while the surgeon went 'where no man had gone before'. After morning's surgical work the deed was done. Betty's triple by-pass was deemed a success.

The life support system was still in operation, keeping Betty's vital organs functioning. But what nobody had seemed to recognize from the medical staffing side, or at least not willing to face at this stage was that Betty was not waking up. Stan became even more restless. He left his nearest and dearest of the past 59 years to telephone his eldest daughter. As they spoke, they each didn't want to voice what their gut instinct was telling them.

Stan quickly returned to the intensive care unit. No change. His 'ever-loving heart' was not waking up as expected.

Betty did wake up, and the nightmare lives on. Betty was not as lucky as her new found friends from the ward at her local hospital who had also had the privilege of 'going private'.

Tragically, while under anaesthetic, Betty suffered a stroke. It was not detected during the open-heart surgery, or in the intensive care unit immediately after the operation. Later, the hospital staff said ther was a 10% chance of such a situation arising. 71-year-old Betty became part of that heartbreaking statistic.

Betty's condition only came to light when her husband Stan insisted something be done to wake her up, because according to what he had been told by the experts, Betty should have come round earlier and been able to respond fully to all the 'post op' checks. Betty showed limited signs of what would have been considered normal. It transpired that Betty had been left paralysed down her right side with severe communication difficulties. Already she was left incapacitated, her life running in slow motion.

Now home again after four months of being institutionalized, Betty has silently suffered (being of the old school as far as manners are concerned), because of the lack of the so called multi-disciplinary approach to care. This should involve all appropriate healthcare professions in the treatment and re-habilitation of the patient, that is to say regular physiotherapy, speech/language therapy, dietary therapy and sporadic occupational therapy. However, Betty is now completely dependent on her elderly husband to care for her day in and day out. She lives a life in a childlike existence.

So, how do you explain to a stroke victim who is paralysed down the whole of one side of their body and afflicted with the ravages of rheumatoid arthritis and osteoporosis that they are not going anywhere? The stroke has changed her and Stan's lives completely.

Stan and his family are thoroughly disgusted and disillusioned with the lack of stroke and neurological rehabilitation care, not only pertinent to their heartbreaking situation, but also from what they have personally witnessed whilst Betty was a ward 'in-mate' of a so called Beacon Site Stroke Rehabilitation Unit in the south of England.

Care staff here were few and professional re-habilitation therapy was sparse or non-existent. When Stan himself talked directly to the head of the unit, he was told that there were 'no funds' for the elderly patients in the unit, and there was a lack of consistent outpatient stroke care and services across the whole the UK.

So tell me please, how do you tell a stroke victim who is all dressed up, that there is nowhere to go?

How many other lives have been affected by the lack of stroke re-habilitation?

(The names Betty and Stan have been used to protect the privacy of these two lovely people.)

Failure of Care

The heart-sickening question needing to be asked of all heart specialists and hospitals is: why was this private section of an NHS London hospital (and how many others) basically not equipped to handle this type of emergency? Further still, why should an emergency arise?

This particular London hospital's cardiac unit centred on-run-of-the mill post-op care. It employed both NHS staff and temporary bank staff who equally displayed a lack of knowledge in caring for a stroke victim. Their lack of professional holistic training was put to the test again three days later when a younger male patient died while undergoing his multiple open-heart by-pass surgery under the same heart specialist that had attended Betty.

Was this anything to do with the seemingly conveyor belt volume of by-pass patients? Or, was it connected with the need to clear the surgery list in time to allow the surgeon to fly to the other side of the world in order to give his services to the infant and junior population who required heart surgery there?

The critical question begs to be asked: despite the availability of the NHS pot of funding, is this well-known teaching hospital really equipped with the specialist staff and facilities to cope with the high volume of heart surgery traffic being filtered in from around the country?

How do we Treat Cardiovascular Diseases?

Recent research at Oxford University suggests that the newly developed fMRI (functional magnetic resonance imaging) enables experts to watch the brain directly as it is working! This technology is moving quickly and opening channels for heart specialists, clinical neurologist and physiotherapists to monitor what exactly happens in brain activity after a stroke.[2] Fascinatingly enough, research using fMRI has already demonstrated the increased brain activity not only near the area of the stroke parts of the brain, but on the unaffected side too. This clearly indicates the natural mechanism utilized by the brain to actively by-pass the damaged tissues.

Aspirin helps reduce the risk of blood clots.[3]

Prevention and Self-Help

Nutrition

One of the most important factors of a healthy heart is correct food consumption, both of types of foods and quantities. The recommendation is to follow a healthy balanced diet of a mixture of protein, carbohydrate, fresh fruit and vegetables, with limited intake of saturated fats and the LDL ('bad') cholesterol found in dairy products and red meat. However, EFAs (essential fatty acids), the 'good' fats such as omega-3 and omega-6 found in oily fish, nuts and seeds, play an essential part in reducing heart disease.

A study conducted by The Lancet of 11,000 heart attack patients who had a daily diet of 100 g of fish oil concluded that this intake resulted in a 45% decrease in the risk of heart attack over three to five years.[4]

Homeopathic doctors counsel as a positive health step to a healthy heart that just a fistful of food eaten five times a day is sufficient nourishment to stay healthy.

A study of men aged between 18 – 68, carried out by the University of Illinois in the United States, found that honey could help in the fight against heart disease. The study suggests that honey contains a range of antioxidants, comparable with the antioxidants found in apples, bananas, oranges and strawberries, that reduce artery plaque.[5]

The Stroke Association's journal, Stroke News, published the findings of scientists at the Tsukuba University in Japan of the risk of stroke in 7,450 patients. It was found that linoleic acid could cut the risk of stroke when patients increased their intake of the acid by 5%. They had a 28% overall reduction to stroke risk. Linoleic acid, found in fish oils, nuts and seeds, may even help stabilize high blood pressure.[6]

Exercise

Regular exercise of at least 30 minutes each session three times a week is now advocated as being the norm in maintaining a healthy body and heart.

A Neuromuscular stimulator has helped some patients to regain the use of the affected leg.

Smokers are more at risk of experiencing a heart attack. Could it be that every time a smoker lights up they are actively participating in slow suicide? Smokers are five times as likely to bring on a heart condition.

Pelvic Floor Exercises

For the more mobile stroke patients, pelvic floor exercises could be the first self re-habilitation move. Pelvic floor exercises help to firm and strengthen the pelvic floor muscles thus improving bladder control by reducing urine seepage, or even to the extent of halting leakage. Holding-up bladder training is another technique used which helps to reduce frequency and urgency to pass water. Drugs can also be used to reduce urine production, reduce bowel movement or to tighten the sphincter muscle.

Catheterization is a very popular option on stroke wards. I wonder why! The catheter tube is inserted into the bladder to drain the urine into a bag.

Continence re-habilitation can take time. Home such aids as pads, panty liners, adult style nappyies and disposable bed linen are available.

Complementary Therapy

Alexander Technique – widely recognized as giving benefit to neuromuscular and movement problems;

Spinal Touch – an exciting healing tool giving immediate benefits;

NLP (neuro linguistic programming) is yet – can be used to condition the mind in overcoming dis-ease. Louise Hay says in her book You Can Heal Your Life that stroke is a sign of 'giving up, resistance and a rejection of life rather die than change';

LifeCoaching – a form of re-habilitation for the mind which brings out PMA (positive mental attitude) and creates a life changing state. LifeCoaching takes the client from where they are to where they want to be – elegantly and fast. It is my belief, as a professional Life Coach myself, that a stroke patient during coaching can experience emotional benefits. Gently but firmly I would coach using numerous tools, but also I would encourage the patient to talk about the positive times before the stroke and to harness those memories and bring them forward to today. As I say my book: "Today is preparation for the next opportunity".

Resources and Bibliography

The Alexander Technique, the essential writings of F. Matthias Alexander, 1989. www.alexandertechnique.com
Spinal Touch www.spinaltouch.com
'Ishta Spinal Touch is a powerful technique for realigning the body's centre of gravity'. The resulting outcome should be a reduction in pain and an increase of functionality, thus allowing the Innate Intelligence to do the job it was designed to do.
Sue Weller BSc., DC. In Touch. 'The Beacon' publications. Autumn 1999. February 2000.
Louise Hay You Can Heal Your Life. Eden. Grove. 1984. www.hayhouse.com
Mona Lisa Schulz MD PhD. (Practising neuropsychiatrist specializing in stroke) Awakening Intuition. Harmony. 1998.
Connirae and Steve Andreas. Heart of the Mind. Real People Press. 1989.
PaTrisha Anne www.lcsi.co.uk Pepper Your Life With Dreams the little book on LifeCoaching and Inspiration Picerjaw. 2002.

References

1. Further information can be accessed at www.rcplondon.ac.uk
2. fMRI is not confined to Oxford University alone, however readerscan access www.fmrib.ox.ac.uk to read more on this function.
3. Anticoagulant drugs and more information at www.uic.edu/collegeofpharmacy
4. A free copy of the magazine The Lancet and The Lancet Neurology is available on request. www.thelancet.com
5. www.uic.edu an informative web site with related stroke research data.
6. www.stroke.org.co.uk a charity 'caring for today, researching for tomorrow and working for change'.

Post Script

The author PaTrisha Anne has herself been tragically touched by stroke to a very close member of her family. Her research into the mine field of stroke disease and rehabilitation as a relative of someone who has suffered a stroke, is on-going.

PaTrisha's work as an International Master LifeCoach and speaker and author has been richly enhanced by this emotional situation which has so suddenly been presented to her.

If you would like to find out more about her work in respect of 'finding the motivation to continue' please call her at LCSi on Tel: 01202 389998.

Further Information

The Continence Foundation will be able to help anyone wanting to make contact with a continence advisor. Tel: 0845 3450165; www.continence-foundation.org.uk
Stroke Awareness Week: administrtaion@stroke.org.uk

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About PaTrisha Anne

PaTrisha Anne is a professional LifeCoach and author of Pepper Your Life With Dreams, the little book on Life Coaching and Inspiration. She can be reached on Tel: 01202 389998; Mob:0771 39 42 305; p.todd53@ntlworld.com; lifecoachschoolinternational Further Information The Continence Foundation will be able to help anyone wanting to make contact with a continence advisor. Tel: 0845 3450165; www.continence-foundation.org.uk

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