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Extended therapy brings new hope for stroke victims

Hundreds of thousands of Americans survive strokes each year only to find they have trouble walking, talking or working and are 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. Most private and government insurance programs then provide for a wheelchair or cane, if necessary, and leave patients 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, Md. Part of the National Institutes of Health, the center funds researchers who are pushing the envelope of expectations for stroke patients.

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 individualized 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 such as dressing, eating and cooking. It's often not enough for people accustomed to independence.

A stroke at 49

Jim Krakowski of Los Angeles knows well the limitations of traditional treatment. The former legislative analyst for the city was left partially paralyzed 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.

Signs and effects of stroke Strokes are caused by blocked blood flow through the brain that occurs either when a blood clot blocks a vessel (called ischemic stroke and responsible for 80 percent of cases) or a vessel bursts (called hemorrhagic stroke and responsible for 20 percent of cases). Both types of stroke cut off oxygen and kill nerve cells. Risk factors include high blood pressure, high cholesterol, smoking, obesity, inactivity, diabetes and family history of stroke, as well as having had a prior stroke or mini-stroke. Warning signs of a stroke include: • Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. • Sudden confusion, trouble speaking or understanding. • Sudden trouble with vision in one or both eyes. • Sudden difficulty walking, dizziness, loss of balance or coordination. • Sudden severe headache that can't be explained. Stroke effects include: • Paralysis or muscle weakness. • Difficulty speaking or swallowing. • Blindness. • Problems with thinking and memory loss. Source: The American Stroke Association Stroke education Harborview Medical Center will sponsor "Living Well with Stroke," a free event for survivors, their families and friends from 8:45 a.m. to noon Saturday in the Research & Training Building, 300 9th Avenue, Seattle. The program will include lectures on stroke prevention, treatment and rehabilitation, financial planning, resources, pharmaceuticals and legal issues. Preregistration: Preregister online or call 206-731-5483.

"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, have little endurance and 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.

More than 700,000 Americans suffer strokes each year, and 170,000 die. Most strokes are caused by clots that cut off blood flow through the brain; others, called hemorrhagic strokes, occur when a blood vessel in the brain bursts.

Stroke is the third-leading cause of death, behind heart disease and cancer, and is the nation's leading cause of disability. The American Heart Association estimates that the cost of stroke-related medical care and disability, including lost productivity, will be $51 billion this year. With the aging of the population and the increasing incidence of two major stroke risks — obesity and diabetes — longtime declines in stroke rates may reverse, experts say.

"Most people have a very nihilistic view of stroke. They think of Grandma living in a nursing home," said physical therapist Pamela Duncan, director of Brooks Center for Rehabilitation Studies at the University of Florida. But 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."

Status quo changing

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 grueling sessions on a specialized 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 Sullivan, a physical therapist and neurology researcher who worked with Krakowski at UCLA before moving to the University of Southern California (USC). She noted that he has retained the improvements he got from the training two years ago.

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

'Never giving up'

Vernell Dugan, 52, is participating in a federally sponsored study of constraint-induced therapy, which also helps reteach the muscles and brain. For 6-1/2 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, physical therapist Michelle Prettyman clocked Dugan's 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 programs elsewhere in the country are charging up to $13,000 for the most severely affected patients, said Carolee Winstein, a USC associate professor of biokinesiology and physical therapy. Patients without insurance coverage typically pay $100 an hour for 12 to 24 sessions of treadmill training, for a total cost of $1,200 to $2,400, Sullivan said.

Insurers might pay for such programs if they saw long-term savings — fewer hospital stays, fewer nursing-home admissions, fewer falls.

Some scientists are experimenting with ways to deliver neuro-rehabilitation more economically. At the Massachusetts Institute of Technology and at the Veterans Affairs Medical Center in Palo Alto, Calif., robots rather than therapists manipulate weakened arms in constraint-induced therapy. At the Rehabilitation Institute of Chicago, a Swiss-made robot called a Lokomat guides paralyzed legs and can do the work of therapists during bodyweight-assisted treadmill training.

Elsewhere, research engineers are devising computer systems that use speech recognition to help patients with speech deficits. Others are creating virtual-reality systems, such as gloves linked to computers that conduct hand therapy.