Reducing Risk Factors for Another Stroke

The principles used for preventing a first stroke and for treating TIAs also apply to stroke patients. For those whose stroke was ischemic, aspirin, warfarin or both will usually be prescribed. Using a neurologist as the primary physician after a stroke, rather than some other specialist or primary care doctor, significantly increases the chance for survival. Some insurance companies may be reluctant to pay for the service of a neurologist; in such cases, patients or their families should be persistent in requesting the best care possible during this important early period. Being treated initially in a stroke unit instead of a general ward appears to play a strong role for better long-term quality of life. 

Candidates for Rehabilitation

In all, 90% of stroke survivors experience varying degrees of improvement after rehabilitation. With current cost cutting, there is pressure to send elderly stroke victims directly to a nursing home rather than try rehabilitation first, although one study found that patients were three times more likely to return home from rehab units than from nursing home. Not all patients, however, need or benefit from formal rehabilitation. If the stroke is severe, intensive training would not be very helpful; if the stroke is mild, patients often improve on their own. To be admitted to rehabilitation, a patient should be able to sit up for at least an hour, be able to learn and be aware, and should have family members or close friends who can be active participants in the rehabilitation process.

Certain early signs can help predict the best and worst candidates for rehabilitation:

 Dysphagia -- the inability to swallow -- is associated with a higher mortality rate, possibly because of increased risk for infection and malnutrition. Incontinence and the inability to recognize nonspeech sounds that occur right after a stroke and a poor hand grip that is still present after three weeks are indicators of severe problems.

Spasticity, on the other hand, may actually be a good sign, because it indicates live nerve action. Patients who are able to move their shoulders or fingers within the first three weeks after having a stroke are more likely to recover the use of their hands than patients who cannot perform these movements. The ability to feel light pressure on the affected hand, however, makes no difference for future hand movement. 

Some Rehabilitation Approaches

Because stroke affects different parts of the brain, specific approaches to managing rehabilitation vary widely among individual patients. Although dead nerve cells cannot regenerate, undamaged brain cells often can take over their functions, and different muscles can be trained to replace those that have been weakened. It is very important that physical therapy be started as soon as the patient is stable -- as early as two days after the stroke. Some patients will experience the fastest recovery in the first few days but many will continue to improve for about six months or longer. About 30% of patients experience aphasia, which is particularly distressing. It is necessary that the patient's family understand that this disability does not necessarily impair the ability to think and partial or even complete recovery is very possible. While professional speech therapy progresses, the patient's caregivers should use and encourage the patient in non-verbal communications, such as pantomime, facial expressions, and pen and paper. Learning and using the sign-language alphabet may be helpful both in communicating and improving small-motor dexterity. Physical exercise relating to the disability caused by the stroke is, in any case, important and may actually help repair the brain. One rehabilitation program found good results with a program that used equipment to retrain muscles and balancing skills. Physical therapy combined with electrical stimulation and biofeedback techniques has also been beneficial. Electrical stimulation of the throat may help patients with dysphagia recover their ability to swallow faster. The use of an amphetamine may help improve motor skills when combined with physical therapy. Another interesting approach for patients with stroke in the right hemisphere uses a special prism and sounds that help the patient to regain the function in the left hemisphere, which suffers neglect when the right hemisphere is damaged by a stroke.

 Drug Therapy for Rehabilitation

Drug therapy can sometimes help relieve specific effects of stroke. For example, the drugs dantrolene (Dantrium), baclofen, and injections of the deadly bacterial toxin botulism have shown some promise in relieving spasticity. In one small study, the drug bromocriptine (Parlodel), normally used for Parkinson's disease, was helpful for patients with severe speech problems, improving their ability to pronounce multisyllable words and to form sentences. Some patients experience intractable hiccups, which can be very serious. Among the drugs used for this condition are chlorpromazine or baclofen. 

Certain drugs commonly taken for conditions associated with stroke may actually slow recovery. They include drugs used for high blood pressure, including clonidine and prazosin, anticonvulsant drugs, the antipsychotic drug haloperidol, and the common anti-anxiety drugs benzodiazepines. 

Managing the Emotional Consequences

Strokes affecting the right hemisphere in the brain increase the patients risk for post-stroke depression. Feelings of great distress are natural after a stroke, in any case, but if depression is prolonged, it can impair recovery. One study showed that people who suffered strokes and became depressed were three times more likely to die within ten years than stroke victims who were not depressed. There is a significantly increased risk of suicide in patients with stroke, especially in women and those under age 60. Anxiety disorder is also common -- occurring in as many as 25% of patients -- and can be debilitating. The two disorders may overlap, but drug treatments for each differ and may offset the other. In addition, many drugs for psychologic disorders and other problems that effect the central nervous system interfere with and can delay rehabilitation. Skilled professional help is needed to determine the most effective and safest treatments. Antidepressants, particularly fluoxetine (Prozac) and similar so-called SSRI drugs, have been beneficial in relieving post-stroke crying.