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Living with stroke
Rehabilitering ved Hjerneslag, Skogli Helse- og Rehabiliteringssenter
Foto: Christopher Olssøn

Rehabilitation and follow-up

If you have had an acute stroke, you need to start rehabilitation quickly.

If you have had an acute stroke, you need to start rehabilitation quickly. The national clinical guideline stroke treatment and rehabilitation of stroke recommends mobilisation within 24–48 hours after onset of symptoms or earlier if the situation is stable. Studies show that early and active rehabilitation increases the likelihood that lost functions can be regained. To succeed, you need to be motivated and have the right amount, intensity, and duration of rehabilitation training.

Quite early on, your medical team will decide which measures are best suited, depending on how you are functioning and the potential for post-stroke rehabilitation. If your functions are moderately impaired you may benefit from a home-based rehabilitation programme. Other patients may require more specialised rehabilitation services. In some cases no rehabilitation needs are identified immediately after the stroke, but challenges requiring follow-up intervention may emerge later on.

The rehabilitation programme offered should have a broad scope, be flexible, and address your specific problems. Services must be interdisciplinary and be provided in all phases of the illness, both at the hospital (stroke unit or rehabilitation unit), in different rehabilitation institutions, and by the municipalities’ health and care services. The rehabilitation chain’s organisation is therefore important. Many different professions and bodies are involved in rehabilitation generally, and especially in stroke rehabilitation. It is also important that the rehabilitation you are offered is tailored to your life circumstances and the life you will be leading going forward. This applies both to rehabilitation services at the hospital or other institution, and to rehabilitation in your home.

Post-stroke rehabilitation must take into account the patient’s own views and thoughts. In order to secure optimum follow-up, patients need to be involved as much as possible.

Brain plasticity

Brain plasticity is a term used to describe the brain’s ability to change and reorganise itself, and its ability to adjust and repair itself after a stroke. Plasticity can help patients regain lost functions in the brain and nervous system, for instance after a stroke. What happens in practice is that the surviving neurons (nerve cells) adjust their structure or change biochemically.

Signals move from neuron to neuron via synapses, which are contact points between the neurons and the nerve fibres. When an injury occurs, this connection stops and neurons die. However, after the injury the neurons can create new connections and a different part of the brain can take over the function of the damaged neurons.

A simplified illustration can show how this works in practice:

IN: The brain’s plasticity – Illustration – Rita Gamlem Kristiansen

The brain is plastic and new brain cells form throughout our entire life. The brain’s capacity for structural change makes it possible for the brain to retrain previously learned functions. To retrain functions it has already learned, the brain must be pushed to practice skills actively. If the brain is not stimulated, it won’t understand that the body needs to be used. This means that if you keep your affected arm quite passive without inviting it to be active, the brain will assume that it shouldn’t be used and the arm will remain paretic.

A few guiding principles:

  • Use your brain or it will be impaired.
  • Use your brain; challenges are good for it.
  • Go in for specific training and repeat the tasks you want to get good at.
  • Pitch training intensity at the right level.
  • Set aside time for the training and pick the right time.
  • Train the things that are important to you.
  • Training has a very short sell-by date. If you don’t keep up the training, its effect weakens.

What effect does training have?

Recent research has shown that the brain has a tremendous ability to reorganise itself after an injury. It is possible for some new brain cells to develop, but what really makes a difference is that other parts of the brain can take over the functions of the damaged part of the brain. This has an enormous impact on rehabilitation and is much of the reason why training helps people get better. When the brain is stimulated through movement and sensory input, you can relearn movements and tasks. The process requires stimulus, i.e. you need to practise those tasks that send signals to the brain to tell it that there is an activity going on. Because this process is particularly active in the initial phase after the stroke it is important to start training early. Therefore everything you do during the course of a day, from performing your morning hygiene routine and brushing your teeth to eating your meals and physical activity (with or without supervision), is considered training.

It is also important that you train movements that are natural, i.e. without using your good side to over-compensate. If you over-compensate, you will develop an acquired passivity on the affected side which could hinder you from regaining your ability to function on that side.

Even though the effect of rehabilitation is greatest just after the stroke, many people who have had a stroke report that they improve even after several years.

Training after a stroke begins already in the stroke unit and for many stroke patients the training goes on for a long time, in some cases years. There are many reasons for training: keeping up the functions you had before the stroke; preventing an increase in muscle tone (muscle rigidity) and awkward movements; preventing pain; enabling independence, and performing different tasks. Training on activities that used to be automatic and/or activities of daily life (ADL) is important. Many stroke survivors have reduced strength, often in one half of the body. In addition, they sometimes have altered sensations, impaired motor control, and coordination difficulties that can affect balance and gait function. Facial paralysis and dysphagia can affect the ability to swallow and eat, and can lead drooling and slurred speech.

These outcomes can be improved with training. Every case is different and regaining impaired functions can make a tremendous difference to life quality.

All training must be individually tailored. Although the general advice is to train at least 30 minutes every day, the most important thing is to train in a goal-oriented way to regain lost functions. Training should build motivation, be varied, and give the stroke patient a sense of mastering functions better. Many patients struggle with fatigue (extreme weariness) and low levels of endurance and the training must be adjusted to the capacity of each person. Studies have shown that stroke patients can benefit from more motor training and that the energy loss from the training is smaller than was assumed.

Training that targets the invisible post-stroke injuries can be just as taxing as motor skills-focused training. Memory, attention, and concentration problems are not visible to the eye, but can be very problematic in everyday life. For instance, if you are training your gait function, deficits in concentration and attention could affect your efforts. Endurance and mental capacity are likely to be lower, especially in the time just after the stroke. Here, too, it is essential that the training is tailored to the individual. Some people can manage more than others. The objective of the rehabilitation is to reduce the damage from the stroke as much as possible, so that you can be as self-reliant as possible.

Home-based rehabilitation with interdisciplinary follow-up is effective, but not right for everyone. Some people benefit from a rehabilitation stay at an institution, while others are able to do much of the training on their own with instruction from a physiotherapist. Stroke patients must be involved in evaluations and decisions throughout the course of their treatment and be given a chance to make decisions on their lives based on their abilities and circumstances. If the patient affected by stroke wants an individual plan and a coordinator, the coordinator holds a key role in facilitating the patient’s involvement throughout the entire therapy pathway.

It is important that you enjoy the training. Examples of training which many people benefit from without over-exerting themselves are swimming and water exercises, walking on flat or uneven terrain, and yoga.

IN: Walkers – photo credit – Christopher Olssøn

Outpatient check-ups with the specialist health service

According to the national guideline for treatment and rehabilitation of stroke, as well as the clinical pathway for stroke, you are entitled to follow-up care. This can be provided by your G.P., the telemedicine network/ambulant team, or check-up appointments at the outpatient clinic. The outpatient stroke clinic offers services to all stroke patients. There should be a final outpatient follow-up appointment with the specialist health service one to three months after you are discharged. These check-ups are important and in aid of multiple objectives: your functional outcome, to secure optimum cooperation between the specialist and the municipal health services, and to ensure that the municipal health service provides high quality follow-up care. Your check-up appointment should be at the relevant stroke unit or rehabilitation unit.

Recommendations:

The check-up appointment should be performed by health personnel with expertise on stroke. The need for secondary prevention and possible rehabilitation requirements should be assessed. If it is difficult to schedule the check-up appointment at the outpatient clinic, it can be arranged at the G.P.’s surgery in cooperation with the specialist health service via an ambulant team or telemedicine network.

The check-up appointment should include:

  1. Introductory chat, discussing the causes and severity of the stroke, and reviewing the course of the illness.
  2. Focusing on preventive therapy/secondary stroke prevention. Reviewing the various medical exams, such as ECG; assessing any additional preventive drugs; measuring your blood pressure; checking your cholesterol, and following up on any risk factors. Mapping any adverse events from newly initiated medication. As part of the check-up appointment, the doctor will discuss your habits, focusing on regular physical activity, quitting smoking, weight management, limiting the intake of alcohol to a moderate level, and a healthy diet. It is also important to discuss plans for preventive therapy and how this will be monitored.
  3. Rehabilitation – should measures be put in place? The appointment at the outpatient stroke clinic should cover a variety of different points: How is your gait function; have you developed spasticity and/or pain? Do you have continence problems? Do you have any language difficulties? Have you developed anxiety or depression? Do you have difficulties with your memory or ability to plan things? Do you have other cognitive problems? Have any recent problems developed in your sexual life?
    What about your involvement in work, driving, free time activities, hobbies, etc.? How are things working for you in your family relationships and other social arenas? How is your life with your partner (including sexual relations) working out? Have you found coping strategies to handle any problems that have emerged?
  4. The plan going forward: At the check-up appointment at the outpatient stroke clinic you should also discuss the evaluation and follow-up of your secondary stroke prevention therapy and rehabilitation, as well as whether an individual plan should be prepared for you. Has a coordinator been appointed for you? The outpatient stroke clinic should send a detailed report to the G.P. and the municipal health service bodies that will be involved in your follow-up care.

If you are having or have had interdisciplinary follow-up after the stroke, it is possible you should be provided with care from the interdisciplinary outpatient stroke clinic.

Source: The Norwegian Directorate of Health