Life after Stroke:
Back to the Gym to help to restore the body function
“Stroke is Singapore’s fourth leading cause of death, comprising 10–12% of all deaths. Its prevalence is estimated at 3.65% for adults > 50 years of age. Approximately three quarters of strokes are ischaemic in nature and one-quarter are haemorrhagic. Stroke is the largest cause of long-term physical disability in Singapore and with a rapidly ageing population, the burden of stroke is expected to increase exponentially in the none too distant future, posing challenges to the healthcare system and society.”
– Stroke in Singapore, Dr Daniel Oh. Consultant. Department of Neurology, National Neuroscience Institute
Everyday, 15 people die from cardiovascular disease (heart disease and stroke) in Singapore. Cardiovascular disease accounted for 29.6% of all deaths in 2015, meaning that nearly 1 out of 3 deaths is due to heart disease or stroke.
A stroke occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and nutrients.
Within minutes, brain cells begin to die.
A stroke is a medical emergency. Prompt treatment is crucial. Early action can minimize brain damage and potential complications.
A stroke may be caused by a blocked artery (ischemic stroke) or the leaking or bursting of a blood vessel (hemorrhagic stroke). Some people may experience only a temporary disruption of blood flow to their brain (transient ischemic attack, or TIA).
Stroke usually does not occur in isolation. Patients with stroke have a high prevalence of associated medical problems.
Ischemic strokes occur when the arteries to your brain become narrowed or blocked, causing severely reduced blood flow (ischemia). About 85% of strokes are ischemic strokes.
Hemorrhagic stroke occurs when a blood vessel in your brain leaks or ruptures. Brain hemorrhages can result from many conditions that affect your blood vessels, including uncontrolled high blood pressure (hypertension), overtreatment with anticoagulants and weak spots in your blood vessel walls (aneurysms).
A less common cause of hemorrhage is the rupture of an abnormal tangle of thin-walled blood vessels (arteriovenous malformation) present at birth.
Transient ischemic attack (TIA)
A transient ischemic attack (TIA), also known as a ‘ministroke’, is a brief period of symptoms similar to those you would have in a stroke.
A temporary decrease in blood supply to part of your brain causes TIAs, which often last less than five minutes. Like an ischemic stroke, a TIA occurs when a clot or debris blocks blood flow to part of your brain.
A TIA doesn’t leave lasting symptoms because the blockage is temporary.
However, do seek emergency care even if your symptoms seem to clear up. Having a TIA puts you at greater risk of having a full-blown stroke, which will then lead to permanent damage later. If you’ve had a TIA, it means there’s likely a partially blocked or narrowed artery leading to your brain or a clot source in the heart.
It is hard to differentiate between a stroke or TIA solely based merely on its symptoms. Up to half of the people whose symptoms appear to go away would, in fact, suffer a stroke, causing brain damage.
Many factors can increase your risk of a stroke. Some factors can also increase your chances of having a heart attack. Potentially treatable stroke risk factors include:
Lifestyle risk factors
- Being overweight or obese
- Physical inactivity
- Heavy or binge drinking
- Use of illicit drugs such as cocaine and methamphetamines
Medical risk factors
- High blood pressure — the risk of stroke begins to increase at blood pressure readings higher than 120/80 millimeters of mercury (mm Hg). Your doctor will help you decide on a target blood pressure based on your age, whether you have diabetes and other factors.
- Cigarette smoking or exposure to secondhand smoke.
- High cholesterol.
- Obstructive sleep apnea — a sleep disorder in which the oxygen level intermittently drops during the night.
- Cardiovascular disease, including heart failure, heart defects, heart infection or abnormal heart rhythm
Other factors associated with a higher risk of stroke include:
- Personal or family history of stroke, heart attack or transient ischemic attack.
- Being age 55 or older.
- Race — African-Americans have a higher risk of stroke than do people of other races.
- Gender — Men have a higher risk of stroke than women. Women are usually older when they have strokes, and they’re more likely to die of strokes than are men. Also, they may have some risk from some birth control pills or hormone therapies that include estrogen, as well as from pregnancy and childbirth.
A stroke can sometimes cause temporary or permanent disabilities, depending on how long the brain lacks blood flow and which part was affected. Complications may include:
Paralysis or loss of muscle movement
You may become paralyzed on one side of your body, or lose control of certain muscles, such as those on one side of your face or one arm. Physical therapy may help you return to activities hampered by paralysis, such as walking, eating and dressing.
Difficulty talking or swallowing
A stroke may cause you to have less control over the way the muscles in your mouth and throat move, making it difficult for you to talk clearly (dysarthria), swallow or eat (dysphagia). You also may have difficulty with language (aphasia), including speaking or understanding speech, reading or writing. Therapy with a speech and language pathologist may help.
Memory loss or thinking difficulties
Many people who have had strokes experience some memory loss. Others may have difficulty thinking, making judgments, reasoning and understanding concepts.
•Emotional problems. People who have had strokes may have more difficulty controlling their emotions, or they may develop depression.
People who have had strokes may have pain, numbness or other strange sensations in parts of their bodies affected by stroke. For example, if a stroke causes you to lose feeling in your left arm, you may develop an uncomfortable tingling sensation in that arm. People also may be sensitive to temperature changes, especially extreme cold after a stroke. This complication is known as central stroke pain or central pain syndrome. This condition generally develops several weeks after a stroke, and it may improve over time. But because the pain is caused by a problem in your brain, rather than a physical injury, there are few treatments.
Changes in behavior and self-care ability
People who have had strokes may become more withdrawn and less social or more impulsive. They may need help with grooming and daily chores.
As with any brain injury, the success of treating these complications will vary from person to person.
Strength Training After Stroke
There has been exponential growth in research investigating the cause of motor impairments and much of this research has addressed the issue of muscle strength.
Muscle strength is defined as the ability to generate force against a load and is assessed as the maximum torque that can be generated during a movement. Two other aspects of muscle strength affected after stroke are muscle endurance and muscle power.
Research reveals that there are changes in neural, muscle structure and function following a stroke that leads to deficits in muscle strength.
Strength training has been advocated for clinically stable stroke survivors and most recently, in the American Heart and Stroke Association’s “ Physical Activity and Exercise Recommendations for Stroke Survivors”. Strength training is performing exercises involving repeated muscle contractions against a load. Studies investigating the effects of strength training in people with stroke clearly demonstrates a marked increase in muscle strength in response to training.
A recent article in NeuroRehabilitation, investigators determined that targeted strength training in patients with muscle weakness due to stroke significantly increased muscle power without any negative effects on spasticity.
It was also suggested that strength training may be most effective when paired with task-specific training. In addition to gains in strength and function, some studies investigating strength training after stroke have demonstrated gains at the participatory level and in health-related quality of life.
Strength training has not been taken up into clinical practice as well as it should, perhaps because physiotherapists overlay precautionary measures in their rehabilitation of people with stroke for the fear of adverse events and negative symptoms (Brazzelli et al 2011, Rose et al 2011). From the studies, no fatal adverse events have been reported in the literature, and strength training in people with stroke is considered a safe and relatively low-risk intervention (Billinger et al 2014).
To minimize any risks, pre-exercise evaluation should include a doctor’s clearance, complete medical history, and assessment to identify absolute and relative contraindications to exercise.
As such, strength training for people with stroke should be carried out:
- Only after a thorough evaluation of the patient’s absolute and relative contraindications to exercise, and the patient’s functional limitations and impairments.
- With specificity: which muscle group is exercised, the range and speed of motion relative to the patient’s functional limitations
- Combined with other forms of training e.g. task specific.
- Following a familiarization period, with the intensity of training progressively maintained or increased as the patient gains strength.
- While monitoring for negative symptoms and modifying the training parameters as required.
Using stabilizing, cueing and supporting techniques to ensure the maintenance of a normal movement pattern during exercise.
At an intensity and dose that is enough to facilitate training overload safely.
In conclusion, deficits in muscle strength are common after stroke and are strongly related to the function of the body. Resistance training increases strength and has the potential to improve function in people with stroke. Barriers to the implementation of strength training in clinical practice may be in part addressed by new knowledge and practical skills.
Strength Training after Stroke: Rationale, evidence and potential implementation barriers for physiotherapists. Nada EJ Signal. MHSc (Rehab), BHSc (Physics), New Zealand Journal of Physiotherapy 2014.
Weight Training after Stroke. Excerpted from “Resist This!” Stroke Connection Magazine. Jan/Feb 2004 (last science update March 2013)
Physical Activity and Exercise Recommendations for Stroke Survivors. Neil F.Gordon, Meg Gulanick, Fernando Costa, Gerald Fletcher, Barry A. Franklin, Elliot J Roth and Tim Shepard. AHA Scientific Statement. www.circ.ahajournals.org/content/109/16/2031
Stroke in Singapore. Dr Daniel Oh. Medical News. www.singhealth.com.sg
Singapore Heart Foundation. Statistics: About the Heart and Heart Disease. www.myheart.org.sg