Striving for a Comeback – Part Two

Part One | Part Two

By: Jean Johnson for Veins1

“Mobility means freedom,” said 61-year-old David Lowell of northern Arizona, two weeks after suffering a severe stroke that affected his left side. “I never appreciated it before. Now, it’s like you’re trapped. Even though I am getting some movement back in my hip, you can’t really do anything by yourself.”

Lowell’s therapists are encouraged, though. He’s young for a stroke, he’s motivated, and he has excellent family support. So he’s up six days a week with his therapists working on the parallel bars and using “something like a skate board that rolls on the tabletop to work my arm.”

To Medical Director of the acute rehabilitation center at Providence Portland Medical Center, Molly Hoeflich, M.D., Lowell’s experience sounds on target. “Typically the leg recovers strength before the arm,” Hoeflich said. “And once a patient starts to get even the slightest movement back, it’s something we can build on. In this field we’re opportunists. We’ll take advantage of anything.”

Hoeflich explained that initial post-stroke therapy generally takes place either at acute rehabilitation centers associated with hospitals or in skilled nursing facilities. Once patients have progressed sufficiently in these programs, then they move to home therapy or outpatient therapy. “Patients usually work on higher functional skills once they move to home and outpatient therapy programs that are usually two to three times a week,” Hoeflich said. “Generally speaking, if patients have families, we train them and rely heavily on their ability and willingness to help carry out the program.”

Traditional therapies include physical rehabilitation in which patients work on mobility and occupational therapy. Therapists use a variety of bars, boards, bands, pulleys, pools and balls to aid patients working on these tasks.

Over the past year, however, two new areas of research are expanding the potential repertoire for stroke therapy.

The Oregon Stroke Center at Oregon Health and Sciences University (OHSU) is one of the leading research centers in the nation and has been involved in two trials that use electrical stimulation in the recovery of hand and arm function. The center is currently awaiting FDA approval to start a third.

Associate Professor in the department of neurology at OHSU and Associate Director of the Stroke Center, Helmi Lutsep, M.D. explained that “A small grid is surgically implanted over the part of the brain that controls the arm. It enables researchers to give electrical stimulation to that area while patients are engaged in physical therapy.

“Patients best suited to these clinical trials are stable,” said Lutsep. “Generally those that are at least four months out from their strokes, although some are as long as a year and a half.

“When strokes heal there are different stages, with the first six weeks being a very active time of healing in the brain when white blood cells are coming in to clean out the inflammation. That’s why we believe that getting rehabilitation started early is important in retraining the brain,” Lutsep said. “But that’s not when things quit. The average is two to three months, but in more severe strokes, improvement continues through the six-month point. Even two years later patients will get new function, although it might be a different mechanism than just the brain healing.”

That said, Lutsep emphasized that gains from the electrical stimulation studies are small ones and that the results are very preliminary. “We’re not talking about a miracle cure. If there is significant weakness, it still stays. What we do notice is improved function as in the case of one woman whose hand would get stuck in her pocket. Now she can pull something out, so to her the stimulation trial was a huge benefit.”

The other encouraging area in stroke rehabilitation is termed “constraint-induced therapy,” or CI. “Therapists pin down the good arm in a sling and then the patient uses the weak arm. Some think the theory is based on the idea that if you pay more attention it will do better. Others think the process retrains the brain, and I think there’s probably more evidence for that,” said Lutsep. “The difficult thing here is that people need to have a certain level of function in the arm in order to be included in the studies.”

Hoeflich added that “most patients in these CI trials are a year out from their stroke. The therapy is six hours a day and extremely intense over the span of two weeks. Not only is it prohibitively expensive, patients tend not to like it. So now what the field is looking at is modified CI over a month’s time at less intense rates.”

“We don’t have CI at my hospital, but we do try and focus on getting the patient to use the affected hand as much as possible,” said Hoeflich. “What’s needed here is a highly-motivated patient and good family support.”

David Lowell’s case comes immediately to mind. Whether he will benefit from the new therapies being studied remains to be seen. Still, he and patients like him with high motivation and a solid network of support in place, will clearly maximize chances for recovery from the debilitating consequences of strokes.