New Hope for Stroke Survivors
Aggressive rehab is crucial—while reducing risk factors
may prevent another crisis.
By Lisa James
June 10, 2011 was the day Erica Tucci’s life turned upside down. Tucci was about to leave her Houston home to go to work “when all of sudden I just collapsed. I had no symptoms, no warning signs, nothing.”
Her son, Brett, came running. “He called 911 and said, ‘My mom is having a stroke,’” Tucci recalls.
Tucci found herself among the nearly 800,000 Americans who have a stroke every year. Like her, most have ischemic strokes, in which a blood clot blocks an artery within the brain. Others have bleeding or hemorrhagic events, in which an artery ruptures. In a transient ischemic attack (TIA), an arterial blockage clears on its own within 24 hours. However, 40% of people who experience TIAs go on to have full strokes.
Stroke risk factors include some that can’t be changed, such as age and family history. But others are “lifestyle risk factors, over which our actions and choices have an influence,” says Leslie Fuller, ND, assistant professor at National College of Natural Medicine in Portland, Oregon. “High levels of stress are linked directly to the number-one modifiable risk factor for stroke: high blood pressure”. Depression has also been linked to stroke, especially among women (Stroke 5/16/13).
Other risk factors include obesity, diabetes and smoking. Stroke can also result from cardiovascular disorders such as coronary artery disease, blockages in the arteries feeding the heart, and atrial fibrillation, an abnormal heart rhythm. One study has found a link between traumatic brain injury and stroke (Neurology online 6/26/13).
Not having risk factors doesn’t mean you can’t have a stroke. “I had low blood pressure. I was working out all the time,” says Tucci, now 54 and author of Radiant Survivor (Publish it Write, ericatucci.com). But doctors discovered a hole in Tucci’s heart, which had sent a clot to her brain. “I used to dance and I would have flutters in my heart. Had I known that the flutters were due to the hole maybe I could have had it repaired before my stroke happened,” she says.
Strokes kill nearly 130,000 people each year, which represents a 30% decline over the last 30 years. “We’ve seen stroke going from the number three cause of death, after heart disease and cancer, to number four,” says Olajide Williams, MD, director of acute stroke services at New York Presbyterian/Columbia University Medical Center in New York City, who cites better detection and treatment of hypertension along with less smoking as prime contributors to the decrease.
Surviving a stroke is one thing. Reversing the damage it causes, though, is another.
Early treatment, Greater Gains
As with a heart attack, getting help immediately is crucial for a stroke. That’s why health authorities
call strokes “brain attacks.” The American Stroke Association (ASA, strokeassociation.org) says you should react to strokes FAST: If you see someone whose Face is drooping on one side, or has Arm weakness or Speech difficulty, it’s Time to call 911.
Don’t let someone’s age fool you into thinking they aren’t having a stroke. Michelle, a strategy manager in her 30s who lives in the San Francisco Bay area, was riding her bike one day “when my vision suddenly changed. Basically the world looked sideways.” She sat down, but “I kept falling towards the right and wasn’t able to see clearly.”
Michelle attributes her stroke to the hormone-based birth control she was using. Williams says a recent increase in strokes among young and middle-aged people in general—a 25% increase in 20 years—is most likely being driven by a rise in disorders such as diabetes and obesity.
Both Michelle and Tucci were treated with clot-dissolving medications, the most notable of which is tissue plasminogen activator (t-PA). ASA treatment guidelines call for administering such drugs within an hour of the patient’s arrival at an emergency room and within four and a half hours of first symptom appearance.
“I am very lucky I had no residual symptoms. My vision corrected itself once the clot dissolved,” Michelle says.
In Tucci’s case, “instead of having vision and speech and cognitive problems, the stroke only affected my right side. I was paralyzed completely.”
Movement problems are among the most common lingering stroke effects, which can also include speech and balance deficits. Such long-term consequences “are mainly determined by how much tissue was affected, the specific area of the brain affected, what type of stroke occurred and how much time passed until medical intervention is initiated,” says Fuller.
Cognitive impairment is also being recognized as a stroke outcome. “We believe that in a lot of the dementia in people who don’t have Alzheimer’s, silent strokes are playing a role. ‘Silent’ is a misnomer,” says Williams.
After a week in the hospital, Tucci went to TIRR Memorial Hermann, “a wonderful rehab center in Houston. Five days a week they had me doing physical (lower body) and occupational (upper body) therapy.”
“The goal of rehab is to promote recovery, improve function and usher the patient back to their usual activities,” says Williams. “Basic activities of daily living can be challenging, simple things like learning how to turn a key in a lock, how to button your shirt, how to use utensils.”
One reason for ambitious rehab is a concept called neuroplasticity: The brain can be trained to actually rewire connections around damaged areas. “I think it is radically changing the face of stroke recovery,” says Fuller. “More patients are being pushed to regain lost function rather than simply learning to deal with lost function.” However, such repair work needs to begin early. “Rather than waiting a week or two, we start getting the patient active as soon as possible,” Williams says. “The period immediately after a stroke has proven to be extremely important.”
Motivation is a crucial factor. “Relearning how to walk and talk is incredibly frustrating,” notes Fuller. “Providing motivation is often integral to the healing process.” This may mean dealing with post-stroke depression as well as post-traumatic stress disorder (PTSD), which has been found to affect 25% of all stroke survivors. These emotional difficulties may be amplified by chronic pain, which affected 11% of stroke patients in one study (Stroke 4/4/13).
Lack of motivation hasn’t been a problem for Tucci. “I never really felt like a victim of my circumstances,” she says. “I believe completely that I will fully recover; it’s just a matter of time.”
One path to recovery that is only starting to be explored in the US is acupuncture, which “has been used to care for stroke for 5,000 years,” says Yihyun Kwon, PhD, DC, LAc, assistant dean of acupuncture and Oriental medicine at National University of Health Sciences in Lombard, Illinois.
“More than 90% of stroke patients in countries such as China, Japan and Korea visit acupuncturists after a stroke.” (These countries use Western medicine in a stroke’s early, acute stages.) For rehab and prevention of recurring strokes, Kwon says he wishes “all stroke patients in the US could benefit from acupuncture.”
Averting a Second (or first) Stroke
Preventing a second stroke is a key part of the recovery process. According to the Centers for Disease Control, nearly 25% of strokes occur in people who have had one previously.
Unlike Tucci and Michelle, who were both healthy before their strokes, most patients need to make significant lifestyle changes. In fact, “much of stroke recovery focuses on second stroke prevention,” says Fuller. “The best way to prevent a second, or first, stroke is to clearly understand and modify all lifestyle risk factors.”
Making such changes may not be easy, but they are effective. In a University of Vermont study involving nearly 23,000 people age 45 and older, researchers looked at the effect of several factors—levels of cholesterol, blood pressure and glucose, plus maintaining a proper weight, not smoking and eating a healthy diet—on stroke risk. Over five years, they found that not smoking was linked to a 40% reduction in risk, while keeping blood pressure at healthy levels reduced stroke risk by 60% (Stroke 6/6/13). Such factors also help improve patients’ overall cardiovascular health.
Fuller’s approach is to control lifestyle issues as much as possible through diet, movement and exercise, and stress reduction, although she says drugs may be needed. She also encourages patients use metabolic numbers—blood pressure and sugar levels, BMI/weight and markers of systemic inflammation—as “goals in understanding and controlling their potential stroke risk.”
The need for changes in a patient’s daily routine makes education one of Fuller’s key functions. “The more I can help patients become motivated and empowered to take their health in their hands, the better the outcome.”
Kwon agrees. “You have to know who you are, what kinds of risk factors you have,” he says. “Some people have high blood pressure, some have diabetes, some have irregular sleeping or eating patterns.” That makes sticking to a treatment plan crucial, “the things you do every single day of your life. Otherwise you give up.”
Giving up is not an option for Tucci, who has moved on from her corporate manager job to “re-enter the world with a new mission in life” helping others face significant challenges. “It’s not an easy task to recover from a stroke. It’s a lot of work,” she says. “But I have to do this work in order to get better. My mantra is, ‘Believe in yourself and watch the miracle unfold.’”