Reversing Paralysis from Stroke

http://strokesupport.in/reversing-paralysis-from-stroke/

Physical activity and Exercise tips for stroke survivors

Stroke is one of the leading causes of long term disability in India. It has emotional, psychological, physical and financial effects on the stroke survivor as well as his/her family. Stroke survivors are predisposed to a sedentary lifestyle that limits performance of activities of daily living, increased risk of falls and heightened risk for recurrent stroke and cardiovascular disease. Activity limitations (also referred to as “disabilities”) are manifested by reduced ability to perform daily functions, such as dressing, bathing, or walking. The magnitude of activity limitation is generally related to but not completely dependent on the level of body impairment (ie, severity of stroke). 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. All the above effects 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. 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

Goals of Physical activity / Exercise

Traditionally, the physical rehabilitation of individuals typically ended within several months after stroke because it was believed that most if not all recovery of motor function occurred during this interval. Nevertheless, recent research studies have shown that aggressive rehabilitation beyond this time period, including treadmill exercise with or without body weight support, increases aerobic capacity and sensorimotor function. The three major rehabilitation goals for stroke patients are preventing complications of prolonged inactivity, decreasing recurrent stroke and cardiovascular events, and increasing aerobic fitness.

 Preventing complications of prolonged physical inactivity

The stroke patient needs to initiate a physical conditioning regimen designed to regain prestroke levels of activity as soon as possible. For inpatients, simple exposure to orthostatic or gravitational stress (ie, intermittent sitting or standing) during hospital convalescence has been shown to prevent much of the deterioration in exercise tolerance that normally follows a cardiovascular event or intervention. Shortly after hospital discharge, the continuum of exercise therapy may range from remedial gait retraining in hemiparetic stroke patients to supervised or home-based walking or treadmill training programs. 

Prevent recurrent Stroke and Cardiovascular events

A reduction of risk factors can decrease the incidence of recurrent strokes and cardiac events. An aerobic conditioning program can enhance glucose regulation and promote decreases in body weight and fat stores, blood pressure (particularly in hypertensive patients), and levels of total blood cholesterol, serum triglycerides, and low-density lipoprotein (LDL) cholesterol. Exercise also increases high-density lipoprotein (HDL) cholesterol and improves cardiac function.

Increasing aerobic fitness

Evidence is accumulating that stroke risk can be reduced with regular leisure-time physical activity in men and women of all ages. It has been proven that men in the moderate- and high-fitness groups had a 63% and 68% lower risk of stroke death, respectively, than men who were in the lowest-fitness group at baseline. Moreover, the inverse association between aerobic fitness and stroke mortality remained even in the presence of cigarette smoking, alcohol consumption, obesity, hypertension, diabetes mellitus, and a family history of heart disease. It is essential that the stroke survivor carries out exercise under the close supervision of qualified medical personnel.

Physical Activity and Exercise Recommendations

Stroke survivors:

• Recurrent stroke and cardiovascular disease are the leading causes of mortality in stroke survivors.
• Physical activity remains a cornerstone in the current armamentarium for risk factor management for the prevention and treatment of stroke and cardiovascular disease.
• Activity intolerance is common among stroke survivors, especially the elderly. Their sedentary lifestyle puts them at risk for recurrent stroke and cardiovascular disease.
• Stroke patients achieve significantly lower maximal workloads and heart rate/blood pressure responses than controls during progressive exercise testing.
• Many factors influence activity level after stroke, including physical, mental, and emotional status. Stroke patients may be more disabled by associated cardiac disease than by the stroke itself.
• Energy expenditure during walking in hemiplegic patients varies with degree of altered body structure and function but is generally elevated, often up to 2 times that of able-bodied persons walking at the same submaximal speed.

Benefits of aerobic conditioning:

• Stroke survivors can benefit from counseling on participation in physical activity and exercise training.
• Research studies show that aggressive rehabilitation beyond the usual 6-month period increases aerobic capacity and sensorimotor function.
• An aerobic exercise program can improve multiple cardiovascular risk factors and thereby have important implications for the medical management of stroke survivors.
• Evidence is accumulating that stroke risk can be reduced with regular leisure-time physical activity in multiethnic individuals of all ages and both sexes. Evidence now suggests that the exercise trainability of stroke survivors may be comparable to that of age-matched healthy counterparts.
• Extrapolation of what is known about the training effects of regular exercise by able-bodied individuals suggests that certain levels of exercise that are achieved during many stroke rehabilitation programs may improve aerobic fitness.

Preexercise evaluation:

• It is recommended that all stroke survivors undergo a preexercise evaluation (complete medical history and physical examination, usually including graded exercise testing with ECG monitoring) before they initiate an exercise program.
• When undergoing exercise testing, the testing mode should be selected or adapted to the needs of the stroke survivor (eg, use of handrails, arm cycle ergometry, arm-leg or leg cycle ergometry).

Recommendations for exercise programming:

• Treadmill walking is highly advantageous as the aerobic exercise mode, with inclusion of resistance, flexibility, and neuromuscular training.
• The combination of comorbidities, neurological deficits, and emotional barriers unique to each stroke survivor requires an individual approach to safe exercise programming.
• For patients unable to perform a graded exercise test, light-to-moderate rather than vigorous exercise should be prescribed, with a greater training frequency, duration, or both to compensate for the reduced intensity.
• Subsets of stroke survivors (eg., those with depression, fatigue syndrome, poor family support, or communication, cognitive, and motor deficits) will require further evaluation and subsequent specialization of their rehabilitation program.
• To enhance exercise compliance, the issues of family support and social isolation need to be addressed and resolved.
• Physical activity and exercise training recommendations for stroke survivors should be viewed as one important component of a comprehensive stroke and cardiovascular risk reduction program. 

Source: Circulation 2004;109:2031-2041

Driving after Stroke

Driving after stroke can be a daunting task. It is not only a major concern of individual safety, but, also public safety on the roads. Given the emotional, physical and financial burden of stroke on the stroke survivor's family, it is, but natural for the survivors to want to get back to work as soon as possible. Often survivors don't realize the difficulties that they might have when driving after a stroke. Some may not know all of the effects of their stroke. Driving against doctor's advice is not only dangerous, but also illegal.

How do I know if I can drive?

Many-a-time, the survivors are so keen to get back to normalcy that they ignore some of the signs and symptoms of unsafe driving. After all, they had been doing that for years before the stroke. 

Ask your family if they have noticed changes. Those around you may notice changes in your communication, thinking, judgment or behavior that should be evaluated before you drive again. They often have many more opportunities to observe changes than others do. 

What are the signs and symptoms of unsafe driving?

• Drives too fast or too slow for road conditions
• Needs help or instructions from passengers
• Doesn’t observe signs or signals
• Makes slow or poor distance decisions
• Gets easily frustrated or confused
• Often gets lost, even in familiar areas
• Has accidents or near misses
• Drifts across lane markings into other lanes

Where can I get help?

Talk to your doctor or occupational therapist. He or she can tell you about your stroke and whether it might change if you can drive. Unfortunately, there are no specific regulations for driving for stroke survivors in India. As such, there are no authorized driver rehabilitation specialists to evaluate driving ability. It would be of great help if the survivors enroll in an authorized driving school and receive instructions on how to modify your driving and the car to compensate for the disabilities. As more capable technologies and new advances in mobility equipment are made each day, wheelchair accessible vehicles have become more powerful than ever before. These modified vehicle solutions – such as hand controls, pedal extensions, seat bases, lifts and ramps – have changed the lives of countless stroke survivors and people with disabilities.

Guidelines in the UK
Driver and Vehicle Licensing Agency (DVLA)/Driver and Vehicle Agency (DVA) sets the rules. After a stroke or TIA you must stop driving immediately, but for many people this is temporary. It is possible to return to driving as long as it is safe to do so and the correct procedures are followed. The DVLA produce a factsheet, Car or motorcycle drivers who have had a stroke or transient ischaemic attack (TIA). This outlines when you have to inform them that you have had a stroke. This guide also applies in Northern Ireland and your medical practitioner may refer to these when advising you.

Cars or motorcycles

If you have a licence to drive a car or motorcycle (category B licence) you are not allowed to drive for at least one month after a stroke or TIA. After a month you may start driving again if your doctor is happy with your recovery. If you have had a number of TIAs over a short period of time you will need to wait until you have not had any TIAs for three months before returning to driving. You will also need to notify the DVLA/DVA.
If you have a licence to drive a large goods vehicle (LGV) or a passenger carrying vehicle (PCV) you must tell the DVLA immediately that you have had a stroke. You are not allowed to drive this type of vehicle for one year. After this time you may be able to resume driving, but this will depend on how well you have recovered and also on the results of medical reports and tests.

Specially adapted cars

Even if you have physical disabilities following your stroke, it may still be possible for you to drive. There are various vehicle adaptations and motoring accessories that can make driving possible and more comfortable. Specialist mobility centres can carry out assessments and provide advice about making adaptations to your vehicle which can enable you to return to driving. They can also provide assessments for passengers who have disabilities, and information on how to safely lift wheelchairs in and out of a car.

Pre-driving assessment tools

1. History to determine previous motor vehicle accidents, number of miles driven, psychosocial aspects, medical conditions and current level of psychological functioning
2. Physical examination to identify subtle physical conditions

• Assess joint mobility of neck, shoulders, wrists, hips, knees and ankles
• Assess upper and lower muscle strength manually
• Assess upper and lower coordination through finger-nose, heel to shin and rapid alternating motion
• Current medication
• Visual fitness
• Mental status

3. Neuropsychiatric testing
4. Off-road driving testing (simulator)

Impact of red tape on the healthcare in India

India is a great nation of over 1.2 billion people. It stands on a 11,000 year old strong culture that is probably matched only by the Mesopotamian culture. It has survived many invaders such as the Arabs and Europeans. After its independence in 1947, India was faced with many problems - poverty, poor healthcare, illiteracy, population explosion, security threats from neighboring countries, to name a few. Since 1980s, economic reforms have propelled India into a an era of rapid growth and development such that the GDP growth during January–March period of 2015 was at 7.5% compared to China's 7%, making it the fastest growing economy. Despite these developments, healthcare sector lagged behind in responding to the healthcare needs of the  nation. 

In a recent article in the New England Journal of Medicine, Dr. KS Reddy states "With weak regulatory systems failing to set and enforce quality and cost standards, some patients receive inadequate, inappropriate, or unethical care. 70% of health care expenditures consist of out-of-pocket spending". Today, the private sector accounts for about 80% of outpatient and 60% of inpatient care. The reasons behind this appalling state of affairs are many. Red tape and corruption are among the top causes leading to the current state of affairs. to state an example, the Supreme Court held the government and the Medical Council of India (MCI) guilty for the loss of 3,920 MBBS seats mainly because of lethargic inspection of infrastructure in medical colleges and non-grant of timely permission to colleges to admit students! Red tape swallows all walks of life from education to filling job vacancies to providing healthcare to the people. 

Failure on the part of any hospital to provide timely medical treatment to a person in need of such treatment results in a violation of the patient's "Right to Life,” which is guaranteed under Article 21 of the Constitution of India. This is the closest India has come to enacting laws similar to The EMTALA (Emergency Medical Treatment and Labor Act) and the COBRA (Consolidated Omnibus Budget Reconciliation Act), which are well recognized in the United States. In 1988, the Honorable Supreme Court of India had stated that every injured person be administered emergency medical care to preserve life and there should be no legal impediment to providing medical care. It is shameful to note that there has been no law to this effect and we, Indians, continue to not care for those in need of emergency medical aid.

How can we change the way we treat our people? Should there be a law enforcing people to care for fellow citizens? Should we punish people who see a person dying but, don't come forward to assist him/her? Should we enforce all the hospitals to provide emergency care? Unfortunately, the problem lies in the mindset of the people more than anything else. How can we get people to care for their fellow citizens? I do not know the answer to this question. But, one thing is sure, IF WE, THE PEOPLE, DO NOT CARE FOR OUR FELLOW CITIZENS, NO ONE ELSE WILL

Stroke Awareness

Please share this video with family and friends to spread stroke awareness

Stroke Warning Signs

Do South Asians stand a higher risk of Stroke?

Stroke or Brain Attack is caused by blockage of arteries or veins in the brain or by bleeding in the brain. It is essential for everyone to remember FASTER to be able to identify stroke and seek treatment immediately. The term FASTER stands for

F - Facial droop
A - Arm or Leg weakness
S - Speech disturbance
T - Time - Call 108 immediately
E - Early - Seek immediate treatment
R - Restore blood supply to the brain

Studies have shown that stroke related deaths are higher among people of South Asian descent (India, Pakistan, Sri Lanka and Bangladesh). The prevalence of high blood pressure, diabetes, cardiac disease, smoking, obesity, rheumatic heart disease, infective meningitis and postpartum stroke are higher in these countries than elsewhere. As such, it is no surprise that the incidence of stroke is also higher in these countries. Added to this is the fact that the level of awareness among people is very low.

How can I reduce the risk of stroke?

• High blood pressure does not have any symptoms so the only way to check is to have your blood pressure measured regularly. If you are over 40 you should get your blood pressure checked at least once every five years and more often if it is high or you have other health problems. This can be done by your GP, or you can check it yourself with a home testing kit.
• Diabetes is a condition caused by too much sugar (known as glucose) in the blood. Having diabetes almost doubles your risk of stroke. This is because high levels of glucose in the blood can damage your blood vessels, making them harder and narrower and more likely to become blocked. If this happens in a blood vessel leading to or within the brain it could cause a stroke. If you have diabetes, you must have regular check-ups with your GP or at a diabetes clinic to make sure your blood glucose and blood pressure stay at healthy levels.
• Atrial Fibrillation is a type of irregular heartbeat that can cause blood clots to form in the heart. If these clots block the blood supply to your brain, it can lead to a stroke. If you have Atrial Fibrillation you can be treated with blood thinning medication such as warfarin, or drugs called novel oral anticoagulants, which can reduce your risk of stroke by 50–70%
• Cholesterol is a fatty substance and is vital for your body to function properly. Most of the cholesterol in our body is made by the liver, but it can also be absorbed from some of the foods we eat.  Too much bad cholesterol in your blood can cause fatty deposits to build up in your arteries and restrict the flow of blood. It also increases the chance of a blood clot developing. High cholesterol has no noticeable symptoms, so you need to have your cholesterol level checked, especially if you are over 40 and have any of the other main risk factors for developing the condition: 
• a history of heart disease or high cholesterol in your family 
• you are overweight 
• you have high blood pressure or diabetes. 

Drugs called Statins can help to prevent fatty deposits forming and reduce your risk of stroke

• Lifestyle 
• Smoking doubles your risk of having a stroke and the more you smoke, the greater your risk. Smoking reduces the amount of good cholesterol in your blood and carbon monoxide from cigarette smoke damages artery walls and makes your blood more likely to clot
• Using gutka, qimam/kimam, paan or naswar is also harmful to your health. Studies have shown that people who use them are more likely to die from a stroke than people who do not. Other products like bidi/beedi and shisha also contain tobacco, so if you smoke these you are at risk of the same kinds of diseases as cigarette smokers, including stroke.
• Regularly drinking large amounts of alcohol greatly increases your risk of stroke.
• South Asian people carry more weight around their waist than the rest of the population. The South Asian Health Foundation suggests that South Asian men whose waist measures over 90cm and South Asian women whose waist measures over 80cm should be considered overweight.
• Eating a healthy, balanced diet can help to lower your blood pressure and the amount of cholesterol in your blood. Eat more fruits, vegetables, fibre and healthy protein and cut down on fat, sugar and salt.
• Steaming, boiling and grilling are all healthier than frying, which adds extra fat. Fried foods such as samosas, pakoras, chips or fried bread like bhaturas or puri should be enjoyed as occasional treats, rather than a regular part of your diet.
• Research shows that regular exercise can reduce your risk of stroke by 27%. You should aim to do at least 30 minutes of moderate physical activity five or more times a week.

Find out more about stroke at www.strokesupport.in