http://www.chronicleonline.com/news/local/following-a-stroke-the-real-work-begins/article_842c78b6-5522-11e8-a8b9-876866c9d475.html
In the case of strokes, time is brain cells. And every moment counts.
That is because once a person has a stroke that involves a blood clot – and about 87 percent of strokes do – they are a potential candidate for a clot-busting medicine called plasminogen activator or tPA.
While the full effectiveness of the drug is still debated, many neurologists believe the drug first approved by the U.S. Food and Drug Administration in 1996 is a stroke game changer, increasing stroke recovery from 20 to more than 50 percent.
But this is where the clock starts ticking after a stroke hits and about 2 million brain cells start dying for every minute without blood flow. This is also where it falls on the stroke victim to start making decisions that will affect the rest of their lives. (So the doctor has no responsibility about stopping the 5 causes of the neuronal cascade of death in the first week? Good to know there is no point in paying your doctor for anything.)
The tPA drug has a window of effectiveness: it should be administered within three hours after stroke symptoms start. That window can be stretched to about 4.5 hours in certain patients.
Every 15 minutes earlier in the start of tPA treatment is associated with patients having 4 percent greater odds of walking independently at discharge, 3 percent greater odds of being discharged to home rather than an institution, and 4 percent lower odds of death before they are discharged from the hospital, according to one recent study published in the Journal of the American Medical Association.
The problems is that about 40 percent of stroke patients arrive at hospitals more than three hours after their strokes, according to one UCLA study.
When tPA isn’t effective alone – in the case of the clot being too large, for example – doctors can turn to endovascular therapy. That is when a neurovascular surgeon inserts a catheter into an incision in the patient’s groin and threads it to the blocked blood vessel.
A retriever at the end of the catheter grabs the clot and the surgeon pulls it out through the incision.
But again, much of the effectiveness of the procedure falls on how swiftly the stroke victim gets themselves to stroke professionals. The American Stroke Association recommends the procedure be performed within six hours
In some cases the person with the stroke is disabled by the event and can’t get help on their own. In other cases, patients ignore the symptoms or are uneducated about stroke symptoms, said Dr. Benna Stanley, a neurologist affiliated with Citrus Memorial Hospital.
Many of those arriving too late are Citrus County residents.
Blame can’t be put on local hospitals here: both Citrus Memorial Hospital and Seven Rivers Regional Medical Center are Primary Stroke Centers.
But stroke therapy does not begin and end in the emergency room. The real work for the patient begins afterward.
After leaving the hospital the patient will either go to a skilled nursing facility, inpatient rehabilitation center, or home.
The goal in rehabilitation is to make the patient as independent as possible.
Once the patient returns home therapy continues in an outpatient facility or during in-home visits.
Selecting an outpatient facility is not easy but it is important.
The patient has the best chance of producing blood flow to damaged areas of the brain, and its peripheral areas, during the first six to 12 weeks after the stroke. After that period of physical and speech therapy, improvement diminishes.
“We know the physical therapy will make a difference,” said Duane Levesque, a physical therapy assistant with Seven Rivers Regional Medical Center.
“But like any disease, it’s a long-term commitment,” he said.
The importance of the physical therapy after the stroke can’t be overstated, Levesque said.
Some of his patients come from other hospitals, some from Seven Rivers.
“The best-case scenario is to keep them in the system,” he said.
That means treating the stroke in the hospital, starting therapy there and then laying out and following up with a treatment plan when they leave the hospital.
“Typically, they’ll have all three: physical therapy, speech and occupational,” he said. “They go under what is a stroke pathway…and there are a lot of players involved.”
But most people know little about selecting a physical therapist or a facility that best suits their needs.
Levesque said that stroke patients can follow some basic strategies when selecting what they want:
*Look for one-on-one care with a physical therapist.
*Look to see that the facility has enough physical therapy assistants for its clients.
*Arrive unannounced and ask for a tour. If staff refuses that should be a red flag that the facility may not be right for you.
*Ask if the therapists have expertise in specific areas and certifications.
A stroke happens when blood circulation to the brain stops. As a result, brain cells die from a lack of oxygen.
There are two broad categories of stroke: those caused by a blockage of blood flow and those caused by bleeding into the brain. A blockage of a blood vessel in the brain or neck, called an ischemic stroke, is the most frequent cause of stroke and is responsible for about 87 percent of strokes. Bleeding into the brain or the spaces surrounding the brain causes the second type of stroke, called hemorrhagic stroke. It is more deadly.
Nicholos Bollin, Citrus Memorial’s rehabilitation services supervisor, also encourages potential patients to watch the interaction between a facility’s therapists and their patients.
When selecting a facility and therapist, Bollin said:
*Take a tour of the facility. His facility includes locker rooms and pool.
*Patients also need to ask questions about what the therapy will include.
*The therapy, while demanding, should still be enjoyable and specific to the patient’s needs. If you’ve had a stroke you want one-on-one therapy not group therapy.
*The facility should be clean and well maintained.
Strokes affect not only the victim’s body and mind, but also their emotions. Many become depressed with how their lives have changed and the work ahead of them.
Bollin said part of a physical therapist’s job is to also motivate his clients.
He also tries to educate his clients on what they can expect from therapy.
“These are all the things you can improve on,” he tells patients. “Based on what we find, your deficiencies, we can improve your strength, your balance, your walking, your ability to stand and be more independent.”
Progress is sometimes slow.
In many cases patients don’t always see the incremental progress they’re making. They get disappointed.
A good physical therapist will redirect that energy toward achieving their goals, he said.
The best patients are those who are optimistic and focused on getting better.
“They say, ‘I’ll do anything. You tell me what I need to do and I’ll do it,’” Bollin said.
Recovering from a stroke is not something a patient should try and do on their own.
Some think “they can just look online and figure it out on their own…but that couldn’t be further from the truth,” he said. “You need to be evaluated by a physical therapist who will create a plan specific to the patient. (What a pile of crap, you'll get guidelines NOT protocols with efficacy percentages.)
“You want a physical therapist with experience with strokes,” he said.
Many doctors recommend rehabilitation centers but patients can choose the facility they want to go to.
Bollin recommends people educate themselves about health-care options, even if they’ve never had a stroke. Learn about the subject and be prepared, he said.
“But it’s human nature and people don’t think about it until it happens to them,” Bollin said.
The problem is that, as time progresses, the stroke will often manifest itself with new symptoms, regardless of whether the patient had rehabilitation. Small islands in the brain near the stroke area, while healthy, can die off after the initial stroke episode. As a result muscles sometimes seize up or the patient has difficulty moving their body in a normal, smooth manner.
That is why rehabilitation should continue beyond the initial couple of months after the stroke, many neurologists say.
But most stroke patients won’t only need physical and occupational therapy.
About a third of stroke patients will also suffer from chronic aphasia, according to a 2015 New Jersey Aphasia Commission report.
Chronic aphasia is the inability to understand or express speech very well due to brain damage from a stroke.
Jennifer Hume is a speech language pathologist with Citrus Memorial.
As soon as possible after a stroke, Hume said patients are evaluated to see if they’ve lost some of their speaking ability or ability to recognize objects.
Hume said her patients run the gambit when it comes to how strokes affect them.
The rule of thumb is that “aggressive treatment early on results in better outcomes for a patient to return to their prior level of function,” she said. “And we are in the patient’s room day one.”
While the hospital sends its own speech pathologist to the patient while in the facility, speech therapy typically continues after the patient is discharged. And if they go home for outpatient or home therapy, they will have to choose a speech therapist.
“You want someone who’s accredited by the American Speech-Language-Hearing Association,” Hume said.
Stroke victims also want to have a good rapport with their speech therapist, Hume said.
An addition, it helps if the therapist also has a good working relationship with the stroke victim’s family.
“A stroke doesn’t happen to just the patient. It happens to everyone in the family,” she said.
Also find a speech therapist that tells you what you can realistically expect from treatment.
“We’re optimistically realistic,” she said. “But you may have a new normal. It’s possible you’re not going to reach your former (ability) 100 percent.”
Just like other therapies, progress is sometimes slow.
Don’t feel overwhelmed, Hume said.
But she understands their lives have typically been turned upside-down.
“Patients are scared,” she said. “They don’t want to lose their independence.”
People’s ability to speak is so fundamental to who they are, Hume said. Their voice enables them to communicate and be heard.
Through their voice and speech they tell family they love them.
When that stops much of their life stops, Hume said.
Her advice: Don’t give up and work hard, she said.
While the task of getting better may seem daunting, “we motivate them…and that’s important (as part of their recovery),” Hume said, “and we remind them that they’re making progress.”
Chronicle reporter Fred Hiers can be reached at fred.hiers@chronicleonline.com and 352-397-5914
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