More hope for stroke patients

New research suggests the recovery process can continue for far longer than before


Hundreds of thousands of people survive strokes each year only to find they have trouble walking, talking or working, dependent on others for the most basic tasks.

Many patients with weakness or paralysis receive some therapy in a rehabilitation hospital or nursing home; others get it on an outpatient basis. But such treatment continues only while they show marked improvement - usually six months at most - and then patients are left to manage as best they can. The progress often stops.

It might not have to be that way. New and ongoing research suggests that stroke patients can continue to improve for far longer, making greater gains and returning to productive lives. But such achievement requires a different type of rehabilitation - one that's more time-consuming, more demanding and much more expensive than the conventional approach.

"I don't think there is any hard limit on how long after a stroke people can continue to recover,'' said Michael Weinrich, director of the National Center for Medical Rehabilitation Research in Bethesda, Maryland, USA. Part of the National Institutes of Health, the centre funds researchers who are pushing the envelope of expectations for stroke patients.

New approach

The new approach, called neuro-rehabilitation, relies on the brain's ability to rebuild itself, to learn new tasks. Adding to evidence of the brain's plasticity, neuroscientists and physical therapists are finding that repetitive, challenging and individualised therapy can rewire the brain and improve stroke patients' ability to move, put words together and articulate them clearly - not just months after their attack, but even years later.

Most current treatment, on the other hand, primarily teaches patients to compensate for their lost abilities by using their "good side'' for daily activities like dressing, eating and cooking. It's often not enough for people accustomed to independence.

Jim Krakowski of Los Angeles knows well the limitations of traditional treatment. The former legislative analyst for the city was left partially paralysed by a stroke four years ago at age 49. Conventional physical and occupational therapy helped him walk again, relying on a cane and a brace, but at a pace of 1 mph, he could hardly get across intersections before lights changed. Although convinced he could do better, Krakowski had exhausted the therapy his health plan would provide.

"The standard for what is an acceptable level of function is too low,'' said neurologist Dr. Bruce Dobkin, head of stroke rehabilitation at the University of California, Los Angeles. Medicare, for example, considers therapy successful if stroke survivors can walk 150 feet. But they may be incapable of climbing stairs or hills, they may have little endurance and they may be forced to use a brace or a cane. "We need to have ways that we can get more people who are really impaired functioning better,'' Dobkin added.

Millions suffer strokes each year, and many of them die. The majority of strokes are caused by clots that cut off blood flow through the brain; others, called haemorrhagic strokes, occur when a blood vessel bursts inside the brain.

Cause of death

In the U.S., stroke is the third-leading cause of death, behind heart disease and cancer, and is the nation's leading cause of disability.

"Most people have a very nihilistic view of stroke. They think of Grandma living in a nursing home,'' said physical therapist Pamela W. Duncan, director of Brooks Center for Rehabilitation Studies at the University of Florida. But the reality is that strokes occur at any age and most patients return home with "sometimes mild deficits that really do limit them and impair their quality of life.''

Experimental therapies, based on a growing understanding of the brain, are trying to change that status quo.

The most promising techniques use treadmills to retrain patients in walking and devices that force patients to use weakened arms. Both can be appropriate depending on the quantity of surviving brain cells and the location of the damage.

In January 2001, Krakowski entered one of Dobkin's pilot studies to retrain the muscles of his weakened leg. He underwent gruelling sessions on a specialised treadmill, strapped into an overhead harness that took some of the weight off his legs, as physical therapists guided his bad ankle and knee and braced his hips.

After 12 sessions, he had increased his pace from 1 mph to 1.4 mph. Functional magnetic resonance imaging showed he was recruiting healthy regions of his brain's motor cortex typically associated with learning new skills. After 30 sessions, he was walking at 1.7 mph. (Most people walk about 3 mph.) Muscle tests showed he'd increased strength and control of his leg. Additional brain scans showed, somewhat surprisingly, that he was now using the brain region healthy people use to control foot movement - a region damaged by his stroke.

"It's neurologically fascinating what's going on,'' said Katherine J. Sullivan, a physical therapist and neurology researcher who worked with Krakowski at UCLA before moving to the University of Southern California. She noted that he has retained the improvements he got from the training two years ago.

Benefit

Sullivan said that up to 80 per cent of stroke patients could benefit from this type of intense retraining of stricken muscles and the nerves that control them.

Vernell Dugan, 52, is participating in a federally sponsored study of constraint-induced therapy, which also helps reteach the muscles and brain. For six-and-a-half hours a day, his right hand is covered by a special mitt, forcing him to use his impaired left arm for a variety of challenging tasks: unlocking a door, pushing a model race car around a sharply curved track, picking up small paper clips and fastening them to a cardboard drink holder.

On a recent day at a USC rehabilitation building, physical therapist Michelle Prettyman clocked his time and called out improvements. On this ninth day of his 10-day training, he had halved his time at several tasks and was lifting his left arm higher.

Dugan cracked a smile. "I'm never going to give up. Never.''

Most patients don't have that option. Krakowski's and Dugan's gains come from the kind of repetitive therapy most stroke patients can't get.

The University of Florida's Duncan has studied the gap between stroke patients' potential for recovery and the limited therapy they receive. It comes down to money.

USC's private physical therapy practice charges paying patients (those who don't qualify for clinical trials) $3,500 for the 65 hours of constraint-induced therapy, while similar programmes elsewhere in the country are charging up to $13,000 for the most severely affected patients, said Carolee J. Winstein, a USC associate professor of biokinesiology and physical therapy.

Some scientists are experimenting with ways to deliver neuro-rehabilitation more economically. At MIT and at the Veterans Affairs Medical Center in Palo Alto, robots rather than therapists manipulate weakened arms in constraint-induced therapy. At the Rehabilitation Institute of Chicag