yulius hermanto
Stroke Rehabilitations, An Important Task
Introduction
Stroke incidence is quite high worlwide, data from United States about 700,000 people suffer a stroke annually, or 1 person every 45 seconds, and nearly one third of these strokes are recurrent.
With the current technology and knowledges about stroke, we could reduce stroke death rate about 12% with proper management. But the bad news is the actual number of stroke deaths increased by 9.9%. This indicates that incidence of stroke is likely to continue to escalate because of an expanding population of elderly especially the baby booming generation; a growing epidemic of diabetes, obesity, and physical inactivity among the general population; and a greater prevalence of heart failure patients. When considered independently from other cardiovascular diseases, stroke continues to be the third leading cause of death in the United States.
Another problem in health that improvement in short-term survival of stroke has resulted increased of population of stroke. Post-stroke persons frequently have significant atherosclerotic lesions throughout their vascular system and are at heightened risk for, or have, associated comorbid cardiovascular disease. Accordingly, recurrent stroke and cardiac disease are the leading causes of mortality in stroke survivors.
Post-stroke patients, usually have some degree of disability, from difficulties in movementes, communications, loss of balance and cognitive disorders. Consequently, stroke survivors are often deconditioned and predisposed to a sedentary lifestyle that limits performance of activities of daily living, increases the risk for falls, and may contribute to a heightened risk for recurrent stroke and cardiovascular disease. Clearly, stroke survivors can benefit from counseling on participation in physical activity and exercise training. However, most healthcare professionals have limited experience and guidance in exercise programming for this diverse and escalating patient population.
Poststroke Sequelae
As stated above, stroke also brings problems or sequelae to the patients, especially related to personal functioning and disability. The WHO’s International Classification of Functioning, Disability, and Health organizes the effects of stroke into problems in the "body structure and function dimension" and in the "activity and participation dimension." Body structure and function effects (known as "impairments"), such as hemiplegia, spasticity, and aphasia, are the primary neurological disorders that are caused by stroke. Activity limitations (also referred to as "disabilities") are manifested by reduced ability to perform daily functions, such as dressing, bathing, or walking.
The degree of activity limitation is generally related to but not completely dependent on the level of body impairment. Other factors that influence level of activity limitation include intrinsic motivation and mood, adaptability and coping skill, cognition and learning ability, severity and type of preexisting and acquired medical comorbidity, medical stability, physical endurance levels, effects of acute treatments, and the amount and type of rehabilitation training. Therapeutic interventions to improve sensorimotor performance after stroke vary considerably. Rehabilitation in post-stroke has shown that improvement both intrinsic motor control and functional status can be achieved.Thus indicates, rehabilitation is important part of comprehensive stroke managements besides controlling the risk factors.
Approximately about 14% stroke survivors achieve a full recovery in physical function, but between 25% and 50% require at least some assistance with activities of daily living, and half experience severe long-term effects such as partial paralysis. Consequently, activity intolerance is common among stroke survivors, especially in the elderly.
Activity intolerance is likely due to several factors, including bed-rest–induced deconditioning, concomitant left ventricular dysfunction, the associated severity of neurological involvement (eg, flaccidity or developing spasticity of the lower extremity and/or impairment of the sensory function of the involved side, impaired trunk balance, spasticity or weakness of the afflicted upper or lower extremity, receptive aphasia, and mental confusion), and the increased aerobic requirements of walking.
Collectively, those variables can create a vicious circle of further decreased activity and greater exercise intolerance, leading to secondary complications such as reduced cardiorespiratory fitness, muscle atrophy, osteoporosis, and impaired circulation to the lower extremities in stroke survivors. The latter may result in eventual thrombus formation, decubitus ulcers, or both. In addition, a diminished self-efficacy, greater dependence on others for activities of daily living, and reduced ability for normal societal interactions can have a profound negative psychological impact.
This situation has several important implications for individuals with stroke and the professionals who counsel them. Preexisting or poststroke cardiovascular conditions can delay or inhibit participation in a therapeutic exercise program, complicate the rehabilitation and long-term poststroke course of care, and limit the ability of the patient to perform functional activities independently.
Post-Stroke Rehabilitation
Rehabilitation in post-stroke survivors helps patients to relearn skills that are lost when part of the brain is damaged. For example, these skills can include coordinating leg movements in order to walk or carrying out the steps involved in any complex activity.
Rehabilitation also train survivors new ways of performing tasks to circumvent or compensate for any residual disabilities. Individuals may need to learn how to bath and dress using only one hand, or how to communicate effectively when their ability to use language has been compromised. There is a strong consensus among rehabilitation experts that the most important element in any rehabilitation program is carefully directed, well-focused, repetitive practice—the same kind of practice used by all people when they learn a new skill, such as playing the piano or pitching a baseball.
Rehabilitative therapy could begins in the acute-care hospital after the person’s overall condition has been stabilized, often within 24 to 48 hours after the stroke. The first steps involve promoting independent movement because many individuals are paralyzed or seriously weakened. Patients are prompted to change positions frequently while lying in bed and to engage in passive or active range of motion exercises to strengthen their stroke-impaired limbs. ("Passive" range-of-motion exercises are those in which the therapist actively helps the patient move a limb repeatedly, whereas "active" exercises are performed by the patient with no physical assistance from the therapist.)
Depending on many factors—including the extent of the stroke—patients may progress from sitting up and being moved between the bed and a chair to standing, bearing their own weight, and walking, with or without assistance. Rehabilitation nurses and therapists help patients who are able to perform progressively more complex and demanding tasks, such as bathing, dressing, and using a toilet, and they encourage patients to begin using their stroke-impaired limbs while engaging in those tasks. Beginning to reacquire the ability to carry out these basic activities of daily living represents the first stage in a stroke survivor's return to independence.
For some stroke survivors, rehabilitation is an ongoing process to maintain and refine skills and could involve working with specialists for months or years after the stroke.
The Plausible explanation of improvements in activity limitation and functioning is brain plasticity. This term doesn't mean that our brain is plastic. But its refers to brain capabilities to reorganize itself, especially when there is a loss of a function in certain part of the brain.
Plasticity is the major explanation for the phenomenon, “If you are driving from here to Milwaukee and the main bridge goes out, first you are paralyzed. Then you take old secondary roads through the farmland. Then you use these roads more; you find shorter paths to use to get where you want to go, and you start to get there faster. These “secondary” neural pathways are “unmasked” or exposed and strengthened as they are used. The “unmasking” process is generally thought to be one of the principal ways in which the plastic brain reorganizes itself.
In Stroke, the damage part was inside the brain, the damage neuron causes loss of function, but our brain is able to reorganize itself to gain the loss function by optimalizing other neurons. Thus proper rehabilitation is important for the brain to optimalizing the "plasticity."
With improvement of daily activity and functioning, will decrease the dependency and improve the quality of life.
Stroke incidence is quite high worlwide, data from United States about 700,000 people suffer a stroke annually, or 1 person every 45 seconds, and nearly one third of these strokes are recurrent.
With the current technology and knowledges about stroke, we could reduce stroke death rate about 12% with proper management. But the bad news is the actual number of stroke deaths increased by 9.9%. This indicates that incidence of stroke is likely to continue to escalate because of an expanding population of elderly especially the baby booming generation; a growing epidemic of diabetes, obesity, and physical inactivity among the general population; and a greater prevalence of heart failure patients. When considered independently from other cardiovascular diseases, stroke continues to be the third leading cause of death in the United States.
Another problem in health that improvement in short-term survival of stroke has resulted increased of population of stroke. Post-stroke persons frequently have significant atherosclerotic lesions throughout their vascular system and are at heightened risk for, or have, associated comorbid cardiovascular disease. Accordingly, recurrent stroke and cardiac disease are the leading causes of mortality in stroke survivors.
Post-stroke patients, usually have some degree of disability, from difficulties in movementes, communications, loss of balance and cognitive disorders. Consequently, stroke survivors are often deconditioned and predisposed to a sedentary lifestyle that limits performance of activities of daily living, increases the risk for falls, and may contribute to a heightened risk for recurrent stroke and cardiovascular disease. Clearly, stroke survivors can benefit from counseling on participation in physical activity and exercise training. However, most healthcare professionals have limited experience and guidance in exercise programming for this diverse and escalating patient population.
Poststroke Sequelae
As stated above, stroke also brings problems or sequelae to the patients, especially related to personal functioning and disability. The WHO’s International Classification of Functioning, Disability, and Health organizes the effects of stroke into problems in the "body structure and function dimension" and in the "activity and participation dimension." Body structure and function effects (known as "impairments"), such as hemiplegia, spasticity, and aphasia, are the primary neurological disorders that are caused by stroke. Activity limitations (also referred to as "disabilities") are manifested by reduced ability to perform daily functions, such as dressing, bathing, or walking.
The degree of activity limitation is generally related to but not completely dependent on the level of body impairment. Other factors that influence level of activity limitation include intrinsic motivation and mood, adaptability and coping skill, cognition and learning ability, severity and type of preexisting and acquired medical comorbidity, medical stability, physical endurance levels, effects of acute treatments, and the amount and type of rehabilitation training. Therapeutic interventions to improve sensorimotor performance after stroke vary considerably. Rehabilitation in post-stroke has shown that improvement both intrinsic motor control and functional status can be achieved.Thus indicates, rehabilitation is important part of comprehensive stroke managements besides controlling the risk factors.
Approximately about 14% stroke survivors achieve a full recovery in physical function, but between 25% and 50% require at least some assistance with activities of daily living, and half experience severe long-term effects such as partial paralysis. Consequently, activity intolerance is common among stroke survivors, especially in the elderly.
Activity intolerance is likely due to several factors, including bed-rest–induced deconditioning, concomitant left ventricular dysfunction, the associated severity of neurological involvement (eg, flaccidity or developing spasticity of the lower extremity and/or impairment of the sensory function of the involved side, impaired trunk balance, spasticity or weakness of the afflicted upper or lower extremity, receptive aphasia, and mental confusion), and the increased aerobic requirements of walking.
Collectively, those variables can create a vicious circle of further decreased activity and greater exercise intolerance, leading to secondary complications such as reduced cardiorespiratory fitness, muscle atrophy, osteoporosis, and impaired circulation to the lower extremities in stroke survivors. The latter may result in eventual thrombus formation, decubitus ulcers, or both. In addition, a diminished self-efficacy, greater dependence on others for activities of daily living, and reduced ability for normal societal interactions can have a profound negative psychological impact.
This situation has several important implications for individuals with stroke and the professionals who counsel them. Preexisting or poststroke cardiovascular conditions can delay or inhibit participation in a therapeutic exercise program, complicate the rehabilitation and long-term poststroke course of care, and limit the ability of the patient to perform functional activities independently.
Post-Stroke Rehabilitation
Rehabilitation in post-stroke survivors helps patients to relearn skills that are lost when part of the brain is damaged. For example, these skills can include coordinating leg movements in order to walk or carrying out the steps involved in any complex activity.
Rehabilitation also train survivors new ways of performing tasks to circumvent or compensate for any residual disabilities. Individuals may need to learn how to bath and dress using only one hand, or how to communicate effectively when their ability to use language has been compromised. There is a strong consensus among rehabilitation experts that the most important element in any rehabilitation program is carefully directed, well-focused, repetitive practice—the same kind of practice used by all people when they learn a new skill, such as playing the piano or pitching a baseball.
Rehabilitative therapy could begins in the acute-care hospital after the person’s overall condition has been stabilized, often within 24 to 48 hours after the stroke. The first steps involve promoting independent movement because many individuals are paralyzed or seriously weakened. Patients are prompted to change positions frequently while lying in bed and to engage in passive or active range of motion exercises to strengthen their stroke-impaired limbs. ("Passive" range-of-motion exercises are those in which the therapist actively helps the patient move a limb repeatedly, whereas "active" exercises are performed by the patient with no physical assistance from the therapist.)
Depending on many factors—including the extent of the stroke—patients may progress from sitting up and being moved between the bed and a chair to standing, bearing their own weight, and walking, with or without assistance. Rehabilitation nurses and therapists help patients who are able to perform progressively more complex and demanding tasks, such as bathing, dressing, and using a toilet, and they encourage patients to begin using their stroke-impaired limbs while engaging in those tasks. Beginning to reacquire the ability to carry out these basic activities of daily living represents the first stage in a stroke survivor's return to independence.
For some stroke survivors, rehabilitation is an ongoing process to maintain and refine skills and could involve working with specialists for months or years after the stroke.
The Plausible explanation of improvements in activity limitation and functioning is brain plasticity. This term doesn't mean that our brain is plastic. But its refers to brain capabilities to reorganize itself, especially when there is a loss of a function in certain part of the brain.
Plasticity is the major explanation for the phenomenon, “If you are driving from here to Milwaukee and the main bridge goes out, first you are paralyzed. Then you take old secondary roads through the farmland. Then you use these roads more; you find shorter paths to use to get where you want to go, and you start to get there faster. These “secondary” neural pathways are “unmasked” or exposed and strengthened as they are used. The “unmasking” process is generally thought to be one of the principal ways in which the plastic brain reorganizes itself.
In Stroke, the damage part was inside the brain, the damage neuron causes loss of function, but our brain is able to reorganize itself to gain the loss function by optimalizing other neurons. Thus proper rehabilitation is important for the brain to optimalizing the "plasticity."
With improvement of daily activity and functioning, will decrease the dependency and improve the quality of life.
