Having a stroke can damage the parts of the brain that help keep balance, leaving some people having a hard time learning to walk again. Problems with balance can mean people are more likely to fall and injure themselves – this being more than just an annoyance and uncomfortable feeling that interferes with their quality of life. It also raises the risk of debilitation and the possibility of fatal falls.

Tai Chi Chuan may help you with these problems. Tai chi Chuan is an inner and highly spiritual ancient Chinese martial art, practiced for integrating body, mind and spirit. According to the philosophy behind the practice, the slow, fluid postures and sequential movements of tai chi focus our concentration while gently working muscles; therefore promoting mind and body calmness and health.

Not surprisingly, modern-day scientists are backing up these ancient claims. Earlier research performed in 2006 by the University of Michigan has previously shown that Tai Chi can improve balance and reduce falls among healthy elders. More recently, researchers at the University of Illinois in Chicago (UIC) have endorsed Tai Chi is a drug-free way to treat these stroke-caused balance problems.

It was in Hong Kong where the study was held, that Mrs. Hui-Chan, professor and head of physical therapy of UIC, and her colleagues decided to try proving that Tai Chi would help stroke survivors. 136 persons who had suffered a stroke more than six months earlier participated in the study. They were put into 2 groups: One practiced breathing, stretching and other exercises that included sitting and walking; the other one, which was the Tai Chi group, practiced a simplified form of this ancient martial art consisting of coordinated movements of the head, trunk and limbs that required concentration and attention to balance. At the end of the 12 weeks study, all the participants were given several balance tests. Both groups performed about the same on a test which involved the ability to stand, walk and sit back down. However, when it came to testing the ability of maintaining balance, like shifting weight, leaning in different directions and standing on moving surfaces… the Tai Chi practicing group clearly showed a significant better performance than the control group did. This study also showed that, in addition to improving balance, Tai Chi improves strength and cardiovascular fitness too.

These results of the research have been published in the January issues of Neurorehabilitation and Neural Repair magazines.

Generally speaking, Tai Chi is a quite beneficial exercise activity for stroke survivors, which is considered low-cost because no equipment and few facilities are needed. What’s more, Tai Chi classes can give seniors opportunities for healthy group interactions that help prevent social isolation, too. We invite you to find out whether there are any Tai Chi classes in your area, and you can also speak to an instructor to ask whether the type of Tai Chi they teach is suitable for people who’ve had a stroke in order to practice movements that will be the most suitable for you.

No doubt, Tai Chi is getting more and more interest from health authorities. The NIH’s National Centre for Complementary and Alternative Medicine (NCCAM) is currently sponsoring studies to find out more about Tai Chi’s benefits, how it works, and diseases and conditions for which it may be most helpful.

Sources:

ScienceDaily.com

Stroke Rehabilitation Journal

Rehabilitation is a dynamic but also progressive process; it enables you with impairments to reach your optimal level, both mental and physical. It helps you to restore the maximal independence and to increase the quality of life.

It is important to have a high-personalized program. If after a stroke, you have complex medical conditions which prevent your participation in a regular stream rehabilitation program, a LTLD program may help you. What does LTLD stand for? The Low Tolerance, Long Duration (LTLD) Unit is a hospital-based program that provides multiple assessments of different disciplines and rehabilitation.

Usually, two types of stroke rehabilitation are usually practiced. It basically depends on the severity of stroke and your age. The disabilities and impairments are evaluated by several kinds of scores, from which doctors can judge the severity of the stroke and therefore put patients into 3 categories: mild, moderate and severe.

The regular stream stroke rehabilitation is geared towards patients with moderate strokes; and are generally 19-75 in age. Typically, they are able to tolerate a minimum of 60 minutes of therapy per session and their overall expected length of stay is approximately 30-60 days. However, stroke rehab patients who are older than 75 years of age may also be suitable for regular stream stroke rehab if they are able to meet these tolerance benchmarks. Regular stream stroke rehab is also able to accommodate stroke rehab patients with severe strokes if they are younger than 55 years of age, able to sit supported for more than 30 minutes at one time and can tolerate a minimum of 30 minutes of therapy per session.

Is LTLD stroke rehabilitation right for you? LTLD stroke rehab is generally geared towards patients with severe strokes. This program is also appropriate for patients who may only have a moderate or mild stroke but are much older like more than 75 years of age. These patients often exhibit higher acuities, more complex care needs, higher resource needs, longer lengths of stay, and demonstrate slower gains in recovery. Depending on the age of the patients and severity of stroke, patients are able to tolerate between 20-30 minutes of therapy per session, and the average length of stay in LTLD stroke rehab generally ranges between 60-180 days.

Apart from the two factors like age and severity of stroke, if you have cognitive impairments and additional disorders or diseases that affect your ability to tolerate the intensity of a regular stroke rehab program, LTLD is a good alternative option. In summary, patients in need of LTLD stroke rehab may:

• Often have suffered from previous strokes
• Have multiple unfavourable disease conditions
• Lack relatively sufficient family support
• Have a sitting tolerance of not more than 5-10 minutes
• Present with aphasia
• Be disoriented with reduced judgment and insight
• Be incontinent

After all, you must be medically stable and demonstrate the potential to learn and improve function.

We are only aware of LTLD stroke therapy being available in Canada where it originated as of today. If you are available of other centres who practice LTLD, do let us know and we will make this information available to our newsletter subscribers.

Take the example of Toronto rehab center. LTLD rehab is provided by an inter professional team including physicians, nurses, physiotherapists, occupational therapists, speech language pathologists, pharmacists, an advanced practice clinician, service coordinator, social worker and other health professionals.

Doctors in Toronto rehab insists on a very goal-oriented rehab program. When a patient arrives, the team works with them to establish some mutual goals and care givers track the success rate of these goals as one of the outcome measures. Patients will not see the drama of high-intensity rehab where significant changes occur in a shorter time. Progress is slow by nature of the type of patients.

It seems that the participants of this program appreciate this innovation. Sylvia, one of the patients under LTLD rehab program, said that LTLD rehab allowed her to regain her strength and confidence so she could once again live independently. “You need to accomplish things within your boundaries. That’s probably the most important thing to realize in this type of program—that people need to work at their own pace and participate as a member of the rehab team.”

Talk to your rehab experts f you are interested in the LTLD rehab program.

Sources:
Greater Toronto Area (GTA) Rehabiliation Network
Toronto Rehab Magazine

As a consequence of a brain injury, the hemiparesis may occur and bring you spasticity, muscle weakness, and a persistent deficit in movement coordination. Such incoordination occurs at least in part because the brain part responsible for mediating an action intention and the part in charge of action execution are no longer intact.

Nearly 80% of people who have had a stroke have more or less trouble moving one side. People with hemiparesis may have trouble moving their arms and legs, difficulty walking and may also experience a loss of balance. As a result, doing simple everyday activities could be difficult. Depending on the damaged area of the brain, the most common type is pure motor hemiparesis: Patients with pure motor hemiparesis have face, arm and leg weakness.

Classic treatment consists of physical the occupational therapy as we mentioned several times in our previous editions. Electrical stimulation to the area of the brain as we presented recently also becomes an interesting treating approach. On the other hand, certain treatments can be helpful in relaxing the muscles in people who have spasticity referring to our last year June’s edition.

A quite common and systematic method is called Modified constraint-induced therapy (mCIT) and it has been presented in our last year January’s edition. It is a focused treatment to stroke patients with hemiparetic arms. Three times a week at their therapist for half an hour each time, patients are asked to practice focused exercises using their weak arm. This therapy could last for 10 weeks. Preliminary studies indicate that mCIT substantially improves affected upper limb use and function in stroke patients.

Certainly, repeated exercises could improve motor activity and allow for smooth controlled movement, as the brain will re-establish the neuronal circuit that mediates voluntary movement. However one disadvantage of this approach is that the recovery is dependent on performance of an impaired limb.

Is there any method independent of the behavioural output of a paretic limb? Yes. Today, we will introduce you another new therapy: Mental Practice, sometimes called Motor Imagery. This therapy is based on when people imagine themselves using a certain body part, areas of the brain and muscles can be activated as if the person is actually doing the activity.

Here is the small model to illustrate one way to do it. The model demonstrates that mirror box for simulation of a left limb moving successfully. The right (unaffected) limb moves around in the “workspace”, giving a reflection of the left (paretic) limb moving successfully in space. You will be instructed to “imaging the reflected limb actually is your limb moving”.

Therefore, your observation of the reflected limb provided a direct perceptual cue of the paretic limb is completing a controlled movement. During the first weeks, you might just have to go through with very simple movements, later in subsequent weeks, you may be asked to do some simple object manipulation like holding a pen drawing some geometric shapes, all this while observing your paretic limb in the mirror.

Such experiment has already been carried early in 2003 in Rehabilitation Institute of Chicago. Patients showed significant increase ability and a decreased in time spent in practicing motor movement tasks. In 2007, a new study in USA which compared the effectiveness of a rehabilitation program with mental practice of specific arm movements to traditional rehabilitation has shown, that the patients receiving mental practice significant increases in daily arm function, which confirmed the previous conclusion.

There are no specific risks involved in participating in motor imagery and it is inexpensive. Motor imagery is actually quite easy to do at home, and many people find it a fun and relaxing way of having additional therapy. Ask your rehabilitation therapist to see if he/she can guide you as to

• how many times a week you should do motor imagery exercises,
• what specific activities and movements you should do,
• what activities you should not do,
• how long each motor imagery session should be,
• how to change activities as you improve.

Have a great imagination journey!

Sources:
American Stroke association
Heart and Stroke Foundation of Canada
Archives of Physical Medicine and Rehabilitation
Reuters

In last month’s newsletter we introduced some exercises for those who have been mildly affected by stroke. If you were moderately affected by stroke, we may have your attention in this time. You many use a wheelchair most of the time, you are probably able to walk, with the aid of another person or by using a walking aid. When walking, you may “lead” with the unaffected side, leaving the other side behind. Therefore, often balance problems and difficulty shifting weights toward the affected side appear.

The purpose of this exercise program is to:

* Promote flexibility and relaxation of muscles on the affected side
* Help return to more normal movement
* Improve balance and coordination
* Decrease pain and stiffness
* Maintain range of motion in the affected arm and leg

Before beginning with these exercises, please be ensured that your clothing will not restrict movements. It is not necessary to wear shorts such as shown in the illustrations, leisure clothing such as sweat suits or jogging suits is appropriate.

Exercise 1: To enhance shoulder motion and possibly prevent shoulder pain
To enhance shoulder motion and possibly prevent shoulder pain: Lie on your back on a firm bed, and interlace your fingers with your hands resting on your stomach. Slowly raise your arms to shoulder level, keeping your elbows straight. At last, return your hands to resting position on your stomach.

Another similar exercise will help you to maintain shoulder motion, especially for someone who has difficulty rolling over in bed. While raising your hand and straightening your elbows, slowly move your hands to one side and then the other.

Exercise 2: To promote motion in the pelvis, hip and knee

Lie on your back on a firm bed and keep your interlaced fingers resting on your stomach. Bend your knees and put your feet flat on the bed. Holding your knees tightly together and slowly move them as far to the right as possible, return to the centre and repeat it by moving them to the left.

Exercise 3: In this exercise, movements needed to rise from a sitting position

Sit on a firm chair that has been placed against the wall to prevent slipping. Interlace your fingers; reach forward with your hands. With your feet slightly apart and your hips at the edge of the seat, lean forward, lifting your hips up slightly from the seat, then slowly return to sitting.

An important thing is to take your time when you exercise. Don’t rush the movements or strain to complete them. If the pain occurs, move only to the point where it begins to hurt. If the pain continues, don’t do this exercise.

Sources:
Circulation Journal of the American heart Association
National stroke association

In February we talked about aphasia, a loss of the ability to produce and/or comprehend language due to injury to brain areas specialized in these functions. In 1989, two scientists showed in their survey that stroke with aphasia have a greater negative impact on the patient’s spouse than stroke without aphasia does. This was explained by the fact that aphasic partners had more difficulty communicating about details concerned with role adjustments.

Already in 1987, two Canadian Scientists, Friedland and McColl studied patients during the first two years after a stroke and identified four aspects of social support which could provide positive and useful help. These were:

1. satisfaction with social support
2. satisfaction with social support
3. the single most significant relationship in the individual’s life
4. close friends and family
5. the community

It is suggested that other approaches to helping the stroke patients could be developed. One way of looking at an aphasic sufferer’s difficult situation is to use the psychological model, Personal Construct Theory (PCT). This method, developed by Kelly in 1955, is a way of describing how we understand ourselves and other people. That is, in Kelly’s terms, the way in which an individual understands the reality of his world, based upon the past he learnt and the future he estimates. PCT can offer a theoretical perspective on the individual’s situation which can enhance our understanding and thus empower us therapeutically.

Used in therapy, it is helpful to view adapting to a stroke as a process of transition, a change of patient’s initial role (spouse, parents etc). That is, the individual comes to understand and make sense of the situation by moving through phases of researching and understanding.

Personal Construct Theory was devised primarily for people with intact language systems – even there was no such mention in Kelly’s original work about this application. However, in case of acquired brain damage, a “grid technique” is widely used today, which is originally from Kelly’s sub-theory: the Role Construct Repertory Test. It aims to elicit constructs from a person by asking them to consider groups of role titles which have been selected from their social context. The role titles are written along the top, and the bipolar constructs are written down the side. Each role title is considered in relation to each pair of constructs.

An example of the procedure would be that three elements are considered:

• Self before illness
• Self now
• Self I would like to be

And put the following words below in the grid:

• very good – very bad
• can move – can’t move
• happy – sad
• angry – not angry
• Calm – more excitable

The grid allows to understand one’s behavior in relation to the aphasic (patient or impatient) and to acknowledge one’s pain because of the loss of abilities. Past-self and present-self may be shown to be significantly far apart which would then form a basis for therapeutic intervention. It helps to set a therapy focus around achievement and being fulfilled. It is possible to distinguish a theme about communication and the ability to socialize.

In a case, Mr. X talks about his distress at his changed ability in talking: “I know I talk slower than what I could do before the stroke, but, it was a shock, because round here people talk quick and I talked quicker than them and I miss the words out, the little words and that. I think it was a shock.”

Note the use of the contrast between before his stroke and afterwards, the pain caused by the loss of his abilities of speech is clear.

Along with PCT, while talking to a stroke survivor with communication disabilities, try to grab adjectives with which he/she describes him/herself, and compare those to the language he/she used before the stroke. Help them with the right and appropriate strategy and give them a positive strength. Personal characterization can also offer a basic starting point.

The application of PCT to our understanding of the reactions to stroke and acquired communication problems can offer theoretical insights which make it easier to understand the meaning of the problem to the individual. It offers a structure to the recovery process.

In the end, here are several communication tips for daily life:

• Personalize the conversation, including using the person’s name to get attention, making eye contact or a gentle touch
• Use short, simple sentences and speak clearly and slowly.
• Repeat sentences exactly, if the person does not seem to understand a word, try substituting it with another one.
• Be specific

Offer simple choices such as “Yes” or “No”.

Sources:
Stroke rehabilitation Journal

Several important factors underscore the potential value of exercise training and physical activity in stroke survivors. Studies have demonstrated the trainability of stroke survivors and documented beneficial physiological, psychological, sensorimotor, strength, endurance and functional effects of various types of exercises. Unfortunately, stroke remains a leading cause of long-term disability. Consequently, stroke survivors are often deconditioned and predisposed to a sedentary lifestyle that limits performance of activities of daily living.

Appropriate exercise does not only help you in the post stroke period, but can also cut stroke risk as a preventive method. Researchers found that as exercise levels increased, stroke risk decreased even after controlling for diet, smoking, high blood pressure, and other risks. Those who exercised the most had half the risk of ischemic stroke (the kind caused by a blockage of an artery to the brain) as the least active.

Walking, bending and stretching are forms of exercise that can help strengthen your body and keep it flexible. A simple activity like sweeping the floor can be undertaken every day. In these two editions of newsletter, we will give you some tips to get you started. We will introduce you to two exercise programs in the following paragraphs. Firstly what we will present is for the person whose physical abilities have been mildly affected by the stroke. In the next issue we are going to talk about exercises for those with greater limitations. The exercises may be performed alone if you are able to do so safely. However, for many stroke survivors, it is advisable to have someone standing beside while an exercise session is in progress.

Exercise 1: To strengthen the muscles which stabilize the shoulder

Lie on your back with your arms resting at your sides. Keeping your elbow straight, lift your affected arm to shoulder level with your hand pointing to the ceiling, then raise your hand toward the ceiling, lifting your shoulder blade from the floor.There is a variation to strengthen the muscles which straighten the elbow: stay in the same position and put a rolled towel under the affected elbow.

Bend the elbow and move your hand up toward your shoulder while always keeping your elbow resting on the towel. Hold for a few seconds, and then straighten your elbow and hold. Slowly repeat the reaching motion several times, remember to lower your arm to rest by your side.

Exercise 2: To improve hip control in preparation for walking activities:

Lie on your back, start with your unaffected leg flat on the floor and your affected leg bent. Lift your affected foot and cross your affected leg over the other leg, lift the affected foot and uncross, then resume the cross motion. Please repeat the crossing and un-crossing motion several times.

Exercise 3: To enhance hip and knee control

Start with your knees bent, feet resting on the floor. Slowly slide the heel of your affected leg down so that the leg straightens. Slowly bring the heel of your affected leg along the floor, returning to the starting position. Keep your heel in contact with the floor throughout the exercise. Taking off the shoes during this exercise is recommended as your foot will slide more smoothly.

Fatigue while exercising is to be expected. You will have good and bad days like everyone else. Certainly these programs can be modified to accommodate for fatigue or other conditions. However, it may be necessary to tolerate some discomfort to make progress.

Sources:
Circulation Journal of the American heart Association
National stroke association