“Even a mild stroke is devastating because all of a sudden, it changes the way you think of yourself and how you do seemingly mundane things,” says Preeti Raghavan, MBBS, a professor of stroke treatment, recovery, and rehabilitation at the Johns Hopkins Medicine Sheikh Khalifa Stroke Institute in Baltimore. Strokes are also incredibly common. The American Heart Association (AHA) estimates that one American has a stroke every 40 seconds. It’s also the leading cause of disability in the United States. But that doesn’t mean that recovery is impossible. According to the American Stroke Association (ASA), about 10 percent of people who have a stroke recover almost completely; 25 percent recover with minor impairments, and 40 percent have lasting moderate to severe impairments that require special care. Dr. Raghavan lent her expertise on stroke recovery, what makes a good care team, and why the future of stroke treatment looks bright. Everyday Health: Stroke can affect people in so many ways. What factors are in play when it comes to how a stroke impacts a person — mobility, cognition, language — and also their ability to recover? Preeti Raghavan: Stroke can indeed affect people in many different ways, and that primarily depends on where the stroke occurs. That is, which blood vessel or which part of the brain gets damaged because of the sudden disruption of blood flow. What ultimately impacts recovery are two things: How quickly someone gets medical attention to restore blood flow to that vulnerable part of the brain, which reduces damage, and how soon they are able to start rehabilitation. Just as in stroke treatment, in rehabilitation, time is critical. The body tries to repair itself pretty much right after the injury. If we can tag team with what the body is already doing by giving rehabilitation of the right intensity during that critical period when the brain is already starting to repair itself, there is the best potential for the patient to get the maximum benefit. If a person has severe impairments in multiple domains — such as speech, language, and mobility — they will need to undergo more rehab and specific rehab that focuses on each of these areas. EH: When it comes to recovery, is there a difference between an ischemic or a hemorrhagic stroke? Or do both cause generally the same impact? PR: There is a difference. The big difference is that hemorrhagic stroke, which is due to bursting of a blood vessel, can usually cause more severe impairment early on. But over time, as the blocked vessel repairs, the recovery can be quicker. The main thing is that we make sure these people don’t develop damage from immobility early on in recovery, such as atrophied muscles, because they often end up doing very well later on. In ischemic stroke, which is due to a blocked blood vessel, you can start with intense rehabilitation right away. It’s important to increase blood flow with things like aerobic exercise early on. That can have an added effect and reduce risk factors for another stroke. EH: Can you explain the difference between cognitive issues and speech impairment after a stroke? Do the two conditions overlap at all? PR: Language issues can overlap with cognitive issues, but not always. Cognition issues are related to attention, executive function, planning, reasoning, and memory. Then there are two kinds of speech issues; one is difficulty with articulation. In this case, the muscles that make the words are not coordinating as well as they should. That is quite separate from cognition; it’s more of a mobility issue. The second is aphasia, which can look different in different people. Aphasia could be expressive, where you have difficulty finding the right words to say. Usually people with expressive aphasia can’t speak in full sentences. For example, they may simply say, “water” instead of, “I would like a glass of water.” It is not just a problem with articulation, it’s a problem with the part of the brain that finds the words. People may also have what’s called receptive aphasia, in which a person can form long sentences but they do not make sense. EH: What kind of timeline for recovery can a person expect after a stroke? How long does it generally take? PR: Recovery really depends on their impairment and the intensity of rehabilitation therapy, and it’s very difficult to predict a timeline. We are getting better at understanding what the key barriers are that we need to address to ensure the recovery process doesn’t stall. We see a lot of patients who come in very severely affected by stroke, but they get early treatment and their recovery is very quick. Now, we’re not talking days. Sometimes, if they are really lucky and they get treated for a clot right away, they could go home within a week. But those are the really lucky ones. For other patients, they have severe impairments and could take much longer to recover enough to be at home. Beyond that, it has a lot to do with the intensity of rehabilitation as well as the severity of the damage. If cognitive function is impacted as well, that will impact how well someone responds to rehabilitation. If they cannot follow instructions, for instance, it might be difficult for them to participate in activities. Recovery doesn’t stop at any particular time after the stroke. For the longest time, people were told that beyond six months, there will be no recovery. Now we know that is not true. We know that the early period is still crucial because we can piggyback on the natural recovery processes that are happening. But beyond that early window, people can still recover. As long as someone continues to work on their recovery, they will improve — it just may take more intense and more hours of focused therapy. EH: What makes a good stroke recovery care team? PR: A good care team is comprehensive and can tackle any of the issues a patient might have. The best teams have a stroke neurologist, a physical rehabilitation specialist, physical therapy, occupational therapist, speech therapist, nurses that specialize in stroke, and psychologists. EH: What about tailoring care? PR: The other key players in the stroke recovery team are the patient and their loved ones. Rehabilitation is one type of treatment that is not just done on the patient. Rather, it encourages the patient to do more of certain activities, and the patient is more likely to do more of something that they like. The patient’s goals, their family support, and the kinds of things they like to do are really important, because rehabilitation after a stroke can feel like drudgery. But if it’s fun, you’re more likely to stay on target. There’s also a lot of new technology coming out that helps people stay on track. EH: Is full recovery after a stroke possible? PR: A full recovery can be possible, but it depends on a number of factors. The severity of the damage and the number of domains impacted can both affect how much a person can recover and how quickly. We do want to manage expectations on how long it will take and how much effort it is. Rehabilitation is a lot of work on everyone’s part, particularly the patients’. The philosophy of stroke rehabilitation has changed dramatically over the past 10 years. It used to be an end-of-life condition where you were left with whatever disabilities you had. But now we know we can harness the recovery processes. Are we able to restore full function? In some people yes, in others not quite yet, but that is the thing: We don’t want to give up.
