Accidente Cerebrovascular

Treatment of effects

After having a stroke and being discharged from the hospital after about 5 to 7 days depending on the severity of the stroke, you will most likely be referred to a neurologist, or a doctor that deals with problems that affect the nervous system. The neurologist will then check for symptoms of various effects known to be caused by a stroke and will refer you to the best rehabilitation for the effects the patient may exhibit. When going to these appointments in the beginning of the recovery stage, it is important that a family member or friend drives the patient there. With that said, here are some of the rehabilitation types you might see and some advice for family and friends for each effect:

Aphasia and Language Effects

That neurologist will most likely refer you to a speech or language pathologist to start with rehabilitation.

The best way to treat aphasia and the corresponding language effects is through rehabilitation. While there are no medications or other treatment options currently available for aphasia, there are different types of rehabilitation options. Evidence shows that therapy is most effective when it is started as early as possible after the stroke has occurred [1]. It might be beneficial to participate in group therapy because it can create an environment where other people are trying to rehabilitate their aphasia as well. It may also be a good place to air particular things about aphasia that are frustrating. Here are some tips to consider for aphasia:

For patients with aphasia

  • Keep a pen and paper with you so you can write down what you want to say (aphasia does not affect the ability to write)
  • Use drawings, gestures, diagrams, or other visual representations of what you want to say.
  • When not with family or friends, keep a card with emergency contact numbers in case of an emergency.

For family and friends

  • Speak slowly and keep your sentences simple.
  • At the beginning, keep conversations just between one person and the patient so as not to overwhelm them.
  • As they become more comfortable, keep people with aphasia involved in group conversations.
  • Create a booklet of drawings, commonly-used words, or needs to make communication easier.
  • Try not to correct them. If necessary, ask for clarification if you are unsure as to what they are asking.

The National Aphasia Association (NAA) has wonderful resources and a caregiver guide that offers steps to help care for someone who has aphasia. Along with the American Heart Association and the American Stroke Association, there are plenty of resources to connect with rehabilitation services. It is possible that the aphasia will be temporary (especially if they suffered a transient ischemic attack) and the patient will recover their full capacity to communicate. Most of the time, however, the changes are permanent. Rehabilitation will help improve the patient's ability to communicate, but the ability will never fully come back. It is important to prepare yourselves mentally and physically for this outcome

Apraxia: Trouble moving any part of the body

There are many different types of apraxia and while all of them involve an extensive rehabilitation program, the challenges differ depending on the limbs or muscles affected. If the patient exhibits apraxia of muscles, occupational therapy might be helpful. The therapists will focus on having the patient mirror or repeat their movements using various cues, such as different tools, diagrams, drawings, and more. Another common approach to treating apraxia of muscles, is verbalization of commands before they happen. For example, before the patient picks up a cup, they say the movements they must do: "I reach for the cup, grasp the cup, bring the cup to my lips, drink, put the cup back down, I release my grasp" [2]. There other treatment options that differ based on the specific type of ataxia. Please consult a healthcare professional to see which treatment plan is best for your unique situation.

If the patient exhibits verbal apraxia (also known as apraxia of speech), here are some common tips that, in conjunction with speech therapy, may improve quality of life:

  • Since some patients experience issues with maintaining a certain cadence of speech, a metronome or rhythmic snapping of the fingers can help one maintain a certain rhythm in speech.
  • The use of pen or pencil and paper to communicate, just like in aphasia, can prove invaluable.
  • A speech-language pathologist may ask the patient to repeat sounds over and over to help them practice making the movements with their mouth.

If the patient exhibits nonverbal oral apraxia, which involves difficulty in moving the lips, mouth or closely surrounding muscles, speech pathology rehabilitation might not be the recommended treatment approach [3-5] Ask a healthcare professional about what may be the best option for your specific situation.

Unfortunately, many people with apraxia can no longer live independently and may have trouble doing tasks that are necessary for daily life. Please consult a healthcare professional to see if this is the case and, if able, try to create a plan that helps keep the patient with apraxia safe.

Dysarthria: "slurred" speech

The treatment plan for dysarthria is extremely similar to the ones for aphasia and verbal apraxia. A neurologist will refer you to a speech-language pathologist where you will do a lot of different rehabilitation exercises. Some of these rehabilitation exercises may include slowing down speech and deliberately over-enunciating words to make mouth muscles stronger. Some pathologists might teach different ways to speak that involve the tongue and lips more than the mouth muscles themselves.

For people with dysarthria, here are some tips that might help improve communication with family and friends (these can also apply for those with aphasia and verbal apraxia):

  • Use one word before you start speaking to create the context for what you are about to say. For example, if you want to ask "What are we going to eat this morning?", the word at the beginning can be "breakfast."
  • Breathe in more deeply to make the words sound louder.

Again, all the other tips and rehabilitation exercises for aphasia and verbal apraxia can be useful for someone who suffers from dysarthria after stroke [6].

Dysphagia: Difficulty swallowing

Dysphagia is very difficult to deal with because swallowing is a complex, neurological process that can be affected by posture, level of moisture in the mouth and even more factors. Some of the main exercises to help rehabilitate involve postural control (do not lean forward when eating food or trying to swallow, since that closes the airway), a tongue hold exercise or resistance training that both increase the strength of the muscles in the throat involved in swallowing [7].

If you cannot go to a speech-pathologist for whatever reason, here is an article that describes 5 home treatment exercises for dysphagia only. Please do not use these for other effects unless otherwise indicated by a healthcare professional.

Vision Changes

As discussed in the "effects of stroke" page, there are many different visual disturbances, but the main ones are spatial inattention (neglect) and visual midline shift. There are others as well that involve the same use of optometric rehabilitation as the main visual disturbances.

Spatial inattention, or neglect, can be fixed through rehabilitation exercises. Some of these exercises may include touching different things that are located on the neglected side of visual space using a full length mirror. This can be done at home for several minutes a day for at least 5 days per week.

Visual midline shift can be fixed through the use of "yoked prisms," which are unique glasses that help to fix the shift in vision [8]. Another type of practice used is to help fix the balance problems that come with visual midline shift by having the patient put more weight on on the unaffected side.

Physical Effects

There are many different physical effects of stroke that all have different treatment plans. This section will focus on the most common ones, but be sure to get the proper rehabilitation exercises for any unique effects from a licensed healthcare professional.

For hemiparesis, modified constraint-induced therapy (mCIT) has become more popular. This version of therapy uses braces or other devices that force the affected side or limb to be used. This force of regular practice may help to improve nerve function. Another type of therapy used is electrical stimulation, which involves sending electrical signals from an electrode to the weakened muscles on the affected side. This forces those muscles to contract, which can improve their functioning. This can also be done by placing an electrode on the brain near the part that controls the affected body part(s), meaning that stimulation of the brain can lead to activation of those muscles. Other things to keep in mind are to use assistive devices, such as canes or walkers, and to make modifications about the home to ensure that when getting out of the shower or off of the toilet, there are extra supports such as bars or plastic sheets at the bottom of the shower floor [9].

For seizures, it is common for seizures to occur within 24 hours of stroke if the patient has suffered a hemorrhagic stroke, a stroke in the cerebral cortex, or a very big stroke. If the patient begins to have multiple seizures per month with no other known causes, then it is possible that the patient has developed a condition known as epilepsy. More than 70% of epilepsy can be treated with the proper medication and if not, then there are specific diets that can reduce the risk of having a seizure [10]. If the patient has a seizure once again, here is a link to a list of Center for Disease Control (CDC) guidelines that one should follow to help ensure patient safety. If someone you know is having a seizure, here are some common guidelines to follow that are detailed further in the link above:

  • Stay with the person until the seizure has ended. Seizures typically take a couple of minutes to pass.
  • Clear everything surrounding the person that is seizing. In some cases, it is a good idea to put a pillow under the person's head.
  • Make sure to tilt their head to the side
  • NEVER try to put anything inside of their mouth, restrain them in any way or try to give them CPR. This may put them in more danger.

For spasticity, occupational and physical therapy have been shown to improve muscle coordination and strength as well as mobility and range of motion. Sometimes casting or bracing of the affected muscles can reduce the tension and can prevent involuntary spasms. Medications are only used when the spasticity is severe and greatly interferes with daily functioning or sleep. Very rarely, if insurance will cover it, botulinum toxin, also known as botox, can be injected to prevent the muscles from contracting at all [11]. However, this is not the most effective way, as there can only be a limited number of injections.

For incontinence, physical therapies and exercises in continent control may be beneficial. Here are three main exercises that can be done to

  • Prompted voiding: a technique that schedules bathroom breaks at specific times. The goal is to increase the time between these scheduled breaks.
  • Urgency control: when you feel the need to go, this technique employs deep breathing and relaxation techniques to help and ignore the need to go.
  • Kegel exercises: exercises that strengthen the pelvic floor muscles (the bottom of the core muscles) to help improve bladder control. For that reason, they are also known as pelvic floor training exercises.

Some behavioral changes that might help are dietary changes that increase fiber and fluid intake and decrease fried or fatty foods [12]. Another way to increase fiber intake is to use medications such as prebiotics (food to help good bacteria grow inside of your gut) or stool softeners and laxatives. For more educational content on treating other physical effects of stroke, the American Stroke Association has an in-depth page that details the rest.

Cognitive Effects

For the treatment of memory loss, treatment focuses on strengthening cognitive skills that hopefully improve memory down the line. The best way to do this is to take notes on things that you must remember and to establish a regular routine that is easier to remember. You can also go to a speech therapist, play games that involve thinking and memory such as puzzles, crosswords, and work with an occupational therapist to help you gain more independence.

For the treatment of vascular dementia, the same steps as above can be followed to help regain important cognitive skills and memory. If the vascular dementia is severe, it might be a good idea to ensure that someone has the ability to make medical decisions for you, should the time for that come. Lastly, manage stroke risk factors such as high cholesterol, high blood pressure, and diabetes [13].

Emotional and Behavioral Challenges

All of the effects and treatments mentioned above will not be able to help treat the emotional challenges that come with someone suffering a stroke. Some people will have to take the brunt of the responsibility by themselves. If possible, please keep tabs on different emotions you may feel not only as a stroke patient, but also as someone who cares for a stroke patient. If you have an extensive family network, please use them, as well as close friends, as a support network to help you get through this difficult time. Even if it may seem out of the question or out of your comfort zone, it might be worthwhile to look into talking to a licensed professional such as a therapist or social worker. If not, then please talk to your friends and family about any emotions you may be experiencing and how to best deal with them in a healthy manner. A more detailed guide for how to deal with these challenges can be found in the "Life after stroke" page.