Therapists discuss prevention, long road to recovery
The worst time to learn about the symptoms of a stroke -- and what's involved in recovering from it -- is after it happens to you or a loved one.
At worst, it can be too late to thwart the event. And the aftermath of a stroke is not the ideal time to grasp how it changes a life, or the lives of family members. It's better to expect the unexpected now -- or at least be prepared in case it happens.
That's the concern of several specialists who render therapy to stroke patients at Charlotte Regional Medical Center (CRMC) in Punta Gorda. A panel of four recently talked with Feeling Fit about what the public should already know -- based on years of experience dealing with patients and their families who suddenly find themselves dealing with stroke.
For starters, stroke can often be avoided -- if you know what to look for.
Ignoring the signs
According to physical therapist Allan Dimaculangan, failure to recognize that a stroke is imminent is a common mistake.
"People will exhibit the symptoms but ignore them," he said. "There are medications that can reverse the stroke or help with full recovery if administered in time."
Common symptoms include numbness on one side, headache, weakness, difficulty speaking or swallowing and loss of vision. In some cases, a hand or arm will go numb, then feeling will return -- then the incident will happen again.
"That's a prime symptom of an oncoming stroke," said speech language pathologist Kristan Repnyek. "People will experience symptoms like these and they say, 'I'll lie down and I'll be fine.' Well, they won't be fine. Even if I had a recurring numbness in a limb the first time, I would go to the emergency room."
Those who don't make it in time, or find themselves suffering a stroke without warning, need to realize what lies ahead.
Learning to communicate
One of the most noticeable results of a stroke could be impairment of speech.
"The patient may know exactly what they want to say and not be able to say it, and they're getting frustrated," Repnyek said. "Then the family member gets frustrated because they know the patient is trying to tell them something and can't. My job is to bridge that gap and give them both a way to communicate."
While the goal is to teach the patient to speak in entire sentences, this -- or even words -- may not be possible at first.
Initial communication may require Repnyek to provide a board with pictures for the patient to point out what he or she wants. Using gestures is also acceptable at this stage. Repnyek encourages the patient's family members and caregivers to keep the communication simple, confining speaking to yes/no questions.
"You need to pull in everything that you have available while you're working on the speech," she said.
But there's another related problem that's also common -- although less commonly known.
Hard to swallow
"The public may not think of swallowing as a problem -- until it actually happens to them or someone they know," Repnyek said. "It's a very common problem with strokes."
When swallowing becomes an issue, the patient undergoes evaluation of the side affected by the stroke. He or she may undergo a modified barium swallow study, in which small amounts of food and liquid are mixed with a contrasting agent so the swallowing process can be seen by x-rays. This will determine if any of the nourishment is entering the lungs, as well as what muscles need attention in order to return to normal swallowing.
"That gives us an opportunity to try different consistencies of food or different postures -- maybe the patient's head needs to be tilted forward," Repnyek said. "There are different exercises, different techniques -- including VitalStim, neuromuscular electrical stimulator -- to help strengthen the muscles after a stroke."
If a simple task like swallowing is difficult, imagine what it's like to stand or walk.
From easy to hard
Rolling or sitting up in bed. Getting on and off a toilet. Retrieving clothes from the closet. Brushing teeth. Combing hair. Preparing a meal.
These are activities most people do without a thought. But a stroke victim may temporarily or permanently lose their ability to perform such simple tasks. Trying to return them to as much independence as possible is the goal of occupational therapist Bob Garofalo. His focus is on "ADLs" -- activities of daily living.
"The first thing we look at is the patient's physical and motor function, and cognition -- to see if they're able to follow any commands," he said. We need to see if they're able to move all of their upper extremity limbs within their range of motion."
In some cases, the muscle tone is so compromised, the patient may have an arm that just hangs uselessly to the side. In a situation like that, a sling, brace or splint may be necessary. Then the patient goes to work with range-of-motion exercises, assisted by the therapist if necessary.
"It may also mean getting adaptive equipment for the patient," Garofalo said, "such as a raised toilet, grabbers for getting items out of reach, a long-handled sponge. Then I give the family suggestions about what they're going to have to do to make their home adaptable for that patient."
While Garofalo concentrates on the patient's upper body, physical therapists such as Evelyn Ambler concentrate on the lower extremities and the trunk.
A world divided
In addition to range of motion and strength, "I'm also interested in can they feel their foot when I touch it," Ambler said, "or if they can balance when I'm getting them to the bed. I'm also going to help them with the skills to roll over, sit up, being able to balance sitting at the edge of the bed, being able to stand up."
In some cases, patients suffer from a condition called neglect, where they lose their sense of left and right because they don't recognize they're using the side of their body affected by the stroke.
"Because a stroke kills brain cells, sometimes it's the ones that tell you what that side of your body is doing in space," Ambler explained. "In other words, you don't normally have to look at your foot to know it's on the floor. A stroke patient would."
There are cases where patients may be looking at their hand and not be aware of it as part of their body.
"They'll say, 'Somebody else's hand is on my bed,' " Ambler said. "They don't think it's theirs."
There may also be a visual deficit where an entire side of the body is not in a patient's line of vision. If there's a plate of food in front of him or her, only half of it will be in view -- a drinking glass or silverware on the wrong side will be out of sight completely.
"That makes it more difficult to do anything because your whole perspective is changed," Ambler said. "So we try to re-train as many brain cells as we can to work as they did before."
Patients often require braces on their feet and ankles to compensate for muscle weakness, so that they can walk. This becomes doubly difficult when a patient can't tell if his or her foot is touching the floor.
"A lot of families need to understand that, for stroke patients, therapy is hard -- it's hard to do," Garofalo said. "It's going to be hard work to recover. And what patients and their families put into it, they're going to get out of it."
She added, "There will be patients that don't want to do it and families that are going to give you grief, but they need to understand we all have to be on the same team to reach a goal and work together to help the patient get better."
While much of the change is physical, there is almost always an emotional component as well.
A stroke can hinder the patient's ability to control emotion.
"Patients can get depressed very easily," Repnyek said. "They'll cry a lot." The depression is usually compounded as the patient recognizes the loss of independence. One of the most traumatic issues, Ambler said, is losing the ability to drive.
"A lot of patients need to understand they're not going to be 100 percent like they were before," Garofalo said. "It may be 90 percent, 80 percent -- and some may not even be able to make that. Physical therapy doesn't mean you're going to be 100 percent, that you'll be able to walk without a walker or cane. Unfortunately, you may spend the rest of your life with that cane or walker."
Any amount or recovery almost always takes time -- which is why the CRMC therapists want people to recognize the symptoms of stroke and get help to prevent it before they become patients.
"You don't get over a stroke in two or three weeks," Ambler said. "You don't even know how much deficit you're going to have for the first two or three weeks. It usually takes a matter of months to recuperate from a stroke."
Charlotte Regional Medical Center is located at 809 East Marion Ave., Punta Gorda. For more information, call 941-639-3131 or visit www.charlotteregional.com.