Today's topic is: "Stroke Rehabilitation"

Our Guest is: Glenn Heiss, Ph.D, 
Department of Rehabilitation Medicine, 
Jamaica Hospital Medical Center

[19:00:17] mod: Tonight it is our pleasure to have with us Dr. Glen Heiss, Psychologist from Jamaica Hospital Medical Center.
[19:00:48] mod: Dr. Heiss will be discussing with us information pertaining to Stroke. Welcome Dr. Heiss.
[19:01:25] Dr._H: Thank you. It's a pleasure to be here tonight.
[19:02:25] mod: Dr. Heiss can you explain what is a stroke?
[19:02:43] Dr._H: Basically, a stroke is an interruption in blood flow to the brain.
[19:02:58] Dr._H: This can be due to a blood clot or a hemorrhage.
[19:03:03] mod: How can this interruption occur?
[19:03:37] Dr._H: Depending upon where the interruption occurs in the brain, the effects can vary.
[19:04:23] mod: Can you plese elaborate more on this?
[19:04:57] Dr._H: Well, usually one side of the body is more significantly affected.  Also, muscle control, speech production, swallowing or even vision and balance can be affected.
[19:06:30] mod: Do all people exhibit the same effects?
[19:07:42] Dr._H: No, every stroke is different. Part of the evaluatin process in rehabilitation is identifying exactly what functions were affected by the stroke and designing a rehabilitation regimen accordingly.
[19:09:45] mod: We have an interesting question from Rail -
[19:10:16] mod: "I've hear that there are two different kinds of strokes - clots and bleeding. Which kind is more severe?"
[19:10:45] Dr._H: Of the two, clots are more common, while strokes caused by bleeding tend to be more severe -- or at least causing more widespread damage.
[19:10:54] mod: Carol asks: We have talked over the last two weeks about stem cell use for TBI. Can this be an effective treatment for stroke?
[19:10:56] mod: <just sitting here>
[19:12:23] Dr._H: I am not personally familiar with stem cell use in treatment of stroke, though I know the area is growing in research and practice. It is an area that will certainly be applied to stroke rehabilitation as much as possible as it is better understood and refined.
[19:12:43] mod: Hi Amanda. Amanda's questions pertains to new technology. With all the new technology that keeps stroke victims alive, we really need to follow up with good therapy scientific research as produced ways of dx. and surgeries, as well as immediate care in the er to reduce damage to the brain. Has rehab. kept u with this in the forming of new ideas.
[19:13:33] Dr._H: Rehabilitation has indeed worked to keep up with surgical and other advances. What we're finding is that a wider array of rehabilitation approaches are effective in optimizing recovery from stroke.
[19:13:35] mod: Amanda: Which is a more useful indicator of brain activity, MRI or PET?
[19:14:43] Dr._H: Both PET and MRI are effective in examining neural activity. The specific choice as to which is used in a given case is a decision made most often by a neurologist or another practitioner who administers such a screening. Both MRI and PET provide an indication of neural activity, indicating which, if any, areas of the brain are damaged or otherwise not functioning optimally.
[19:15:40] mod: Carol: What is the newest method of treatment for stroke today and how effective is it?
[19:17:23] Dr._H: Strokes are still primarily treated with combinations of physical manipulation and strengthening exercises. The latest trend, I would say, has been an increased focus in attention to the affected side of the body. Nowadays, many advocate re-training the affected side as much as possible -- rather than focusing on letting the non-affected side compensate for the weakness or impairments caused by the stroke.
[19:17:51] mod: Has public education kept up with the use of TPA for clot based strokes. I know that there was a two hour to the ER limit on early trials with the "clot buster" but has the public been given enough information to recognize Stroke onset early enough to be treated with TPA? I haven't seen much in that area on the News!
[19:19:05] Dr._H: What a good question. To take the second half first: No, I don't think the public is as well-educated as they could be to detect strokes as early as possible. Headaches, one-sided muscle weakness, dizziness, blurry vision, nausea, loss of speech and difficulty swallowing, all early sings of stroke, should be addressed immediately and medical attention sought. "Clot busters" and other medications which help ameliorate the effects of stroke are certainly most effective when administered as soon as possible.  So, the more public education, the better!
[19:19:57] mod: Carol: What are the criteria for each MRI or PET? How do you know which is better for the patient?
[19:22:11] Dr._H: That's an excellent question, Carol, and one that I am not ideally suited to answer. As I said, a neurologist or other hands-on medical professional will make that decision based on factors like the age and health of the patient, whether or not she/he has other medical conditions which contraindicate either an MRI or a PET, and based on exactly what kind of brain activity is being examined.
[19:22:12] mod: Ed: Can migraines cause strokes?
[19:23:37] Dr._H: Migraines, per se, cannot "cause" a stroke. However, the muscle tension and stress often associated with migraines can increase the risk or stroke due to increased blood pressure and recurrent episodes of fatigue which often accompany migraines.
[19:24:14] mod: Rail: On Carol's question - Isn't the availability of PET rather limited - with MRI and functional MRI being more readily available?
[19:25:09] Dr._H: I think it's safe to say that MRI and functional MRI are more common, but when dealing with brain injuries such as strokes, efforts are made to obtain the most appropriate, relevant test -- whether PET, MRI or CT scan.
[19:25:48] mod: ED: I sometimes hear people talk about "mini strokes" what is that and how does it happen?
[19:28:14] Dr._H: That is a very good question and something that many people do talk about. A "mini-stroke" is usually a TIA or "transient ischemic attack" -- this is also an interruption in blood flow to the brain but with effects that are usually milder and briefer in duration. However, a mini-stroke or "TIA" is often a precursor to an actual full-blown stroke. This is another reason why the symptoms I mentioned above should be addressed immediately.
[19:28:15] mod: Do strokes run in families? And can a person have more than one stroke?
[19:29:29] Dr._H: A person can indeed have more than one stroke. Often, subsequent strokes are more severe than the first one. While stroke itself does not run in families, the risk factors for stroke do. These include hypertension, diabetes, high cholesterol and depression.
[19:30:09] mod: Rail: Are there "early" indications of the severity of a stroke - in the 4-10 day range after the episode?
[19:31:46] Dr._H: While each stroke is different, there are certain types which are more severe because they occur in parts of the brain which manage basic functions, such as respiration. In other cases, the extent of paralysis (called paresis with regard to stroke), is one early indicator of severity. However, even "severe" strokes can be treated in rehabilitation, allowing the individual to regain optimal functioning.
[19:32:49] mod: How often does a stroke person regain their full functional capacity?
[19:34:26] Dr._H: "Full" functional capacity is often not regained -- if for no other reason than the fact that some damage to the brain did occur. However, individuals often regain much of their pre-morbid functional capacity. It has bene estimated that anywhere from 5% - 15% of stroke survivors recover virtually all functioning.
[19:34:27] mod: My Dad had several small TIA's. After how many small mini strokes do you continue to rehabilitate an individual?
[19:35:46] Dr._H: Rehabilitation after a TIA (or multiple TIAs) is always appropriate if there has been disruption in functioning and the individual's medical condition does not contraindicate rehabilitation.
[19:35:47] mod: Could you tell me a little more about how depression can cause a stroke?
[19:37:30] Dr._H: Depression can be related to stroke because it is so frequently associated with higher levels of stress (which is linked with high blood pressure) and, obviously, depressed mood, which is linked with decreased physiological health overall. Therefore, a depressed person is more likely to be severely affected by a stroke and have a more difficult time recovering.
[19:37:31] mod: Does a stroke always affect a persons cognition? And if not what areas of the brain affect the memory, cognition?
[19:39:12] Dr._H: Not all strokes necessarily affect cognition or memory. Strokes in the cerebellum are frequently associated with impairments in motor coordination but not necessarily cognition. Strokes in the temporal lobe are very likely to produce memory impairment, as are strokes in the parietal lobe.
[19:39:12] mod: Amy: Can the opposite side of the brain where the stroke took place compensate for the side that was affected?
[19:40:23] Dr._H:
[19:41:00] Dr._H: Excellent question! In a general sense, rehabilitation tries to 'train' the opposite side of the brain to pick up for the affected area.  Some areas of functioning which are more generalized in the brain are more amenable to such accommodation.  Younger people, it seems, are also better able to adapt to stroke because younger brains are more adaptable.
[19:42:24] mod: Rail: Has there been much study on the "affects" a stroke can have in the frontal lobes of the brain? Do these individuals begin to act "lobotomized?
[19:43:58] Dr._H: Yes, frontal lobe strokes (or frontal lobe damage of any kind, really), tend to produce a range of effects including, occasionally, increased aggression, decreased impulsivity, and often a "flat" or masklike appearance. These individuals may also become more detached from the people around them.
[19:43:59] mod: Amy: I've notices that with my husband that his personality has changed since the stroke...why and will he ever be the same?
[19:44:52] Dr._H: Personality can be altered by a stroke because of the damage sustained by areas of the brain which govern things like our attitudes, our impulse control and our frustration tolerance.  Your husband may not ever return to the exact individual he was before his stroke, but with time and repeated reminders or reinforcements of what he was like before the stroke, he may recover additional elements of his personality which you do not currently see.
[19:46:17] mod: How can you get an noncompliant person to take their hypertensive medication regularly? Especially when they think their fine?
[19:47:48] Dr._H: That is an excellent and a challenging question. We are all non-compliant with things like medication prescriptions for different reasons. Sometimes we don't appreciate the risk we are taking, sometimes we don't fully understand why we should comply and sometimes we're just afraid and we try to avoid the issue altogether, though that seems so unproductive.  A good strategy is to try to assess why a person is non-compliant, then try to provide the education, support or insight they need to better appreciate the importance of compliance.
[19:48:45] mod: AJM: Any new information on regenerating brain cels as a way of amending the damage of a stroke?
[19:49:35] Dr._H: This is not an area in which I am very well-versed, though I am aware that research in this area is growing rapidly -- particularly as cell regeneration skills develop.  At a later date, the moderate informs me, we will try to schedule a chat with an expert in this area. Stay tuned!
[19:50:16] mod: AJM: Caregivers are under alot of stress what is the possiblit that they also can have a stroke...have you ever seen this?
[19:51:20] Dr._H: Well, the stress placed on caregivers is certainly great, and since stress can increase risk of stroke, yes, such an individual could be at a greater risk.  There are a number of caregiver support services and groups available, however (several of which are disucssed elsewhere on the website) which I strongly recommend.  As they say, if we do not take care of ourselves, by obtaining support, for instance, we will be less effective in taking care of those who need us.
[19:52:52] mod: They say you can prevent strokes. Can you describe some preventative measures?
[19:54:11] Dr._H: You can certainly help reduce risk factors for strokes. Issues such as: stress management, blood pressure management, diabetes management -- whether through diet, medication, supportive therapies or any combination of these can be effective strategies to reduce stroke risk.
[19:54:12] mod: I've worked with many stroke patients who seem to want to give up because of the physical devastation of the stroke. What suggestions could you give me to help motivate this type of individual?
[19:54:37] mod: Hi Melanie and welcome!
[19:55:50] Dr._H: Feelings of hopelessness and helplessness are, sadly, quite common after a stroke. Involving family members and other significant individuals in the person's life is an important first step. In addition, psychiatric medications like antidepressants, and therapeutic interventions like support groups or psychotherapy are also helpful and frequently used.
[19:55:52] mod: AJM: I know that there is such a thing as a locked in syndrome how does that happen? Has anyone ever recovered to give an account of this?
[19:57:14] Dr._H: With regard to "locked in syndrome," this is sometimes described as a "waking coma" where an individual is aware of her/his environment but cannot communicate that awareness.  This is similar to the experience of a stroke victim whose expressive language abilities are impaired.  As to the specific cause(s) of this syndrome, I must confess ignorance. I have heard of individuals recovering, but this is anecdotal as far as I know. If others have more information, chime in.
[19:58:40] mod: What is an appropriate diet for a stoke?
[20:00:21] Dr._H: In general -- a diet low in fats and cholesterol and low in salt are the primary recommendations. Moderate alcohol consumption (no more than one or two drinks/day) and more vegetables and pastas are also often recommended.
[20:01:09] mod: Well our time is up and I want to thank Dr. Heiss for an excellent evening of chat discussion. I welcome him to return with us on another evening.
[20:01:22] mod: Good night to all and thank you for being with us this evening.
[20:01:53] Dr._H: Thank you for all the excellent questions. I would be delighted to return for another chat. Thank you!