Stroke rehabilitation

I thought in this post I shall discuss a little about stroke rehabilitation. A stroke can be devastating and causes significant morbidity and mortality. Stroke survivors are frequently left behind with neurological deficits. Common deficits include: motor (weakness on one side of the body usually arm and leg), speech deficits (patients may be left with a significant disorder of language. We call this aphasia and patients may have either difficully in comprehending speech or in the fluency of speech. Their speech may be slow and halting. At times they also have what we refer to as nominal aphasia also called anomia. These patients experience difficulty in naming things, like for example if you show them a pen, they would not be able to tell you that it is a pen. They shall know what it is used for but cannot get the name out). Patients may be left behind with residual numbness on one side of the body and depending upon the location of the stroke they may experience difficulty with seeing one half of their visual field (we call this a field cut). Some stroke patients are disabled by ataxia or unsteady gait, others may have disabling cerebellar symptoms.

Stroke rehabilitation plays a big role in the care of stroke patients. Contrary to popular held views, rehabilitation starts right at the onset of stroke and not once the acute stroke is over and the patient is been discharged. Now most of the big hospitals in the United States have acute stroke units. One of the biggest tenants of these acute stroke units is that rehabilitation is started soon after the patient presents to the hospital with an acute stroke. Studies have shown that the human brain has the maximum ability to heal and repair itself acutely (upto 6 months to a year) after a stroke. As time goes on, the brain loses this plasticity and the neurological deficits become more or less fixed. Thus  rehabilitation in the acute stroke setting plays a vital role. Usually patients are evaluated by physical medicine doctors (rehab doctors) while they are still in the hospital with the acute stroke. An assessment is made of their deficits and depending upon that we decide which rehabilitation services are needed. Patients may get physical and occupational therapy in the hospital. They may also be seen by a speech and language therapist so that speech therapy can begin.

Nowdays there are many different modalities of rehablitation therapy which have been proven to be of benefit to patients with stroke. One of the popular ones is constraint induced movement therapy. In this the good arm of the patient is immobilized so that the patient is forced to use the weak arm. Melodic intonation therapy has recently gained popularity too. This therapy uses a style of singing called melodic intonation to stimulate activity in the right hemisphere of the brain in order to assist in speech production in patients who have aphasia.

Stroke rehabilitation does not end once the patient is discharged from the hospital. Most of these patients benefit from ongoing rehab (as I stated earlier this mostly occurs in the first 6-12 months). Patients may either be discharged to a rehab unit or a sub acute rehabilitation facility where these therapies can be carried out in a less hospital like atmosphere.

It is Saturday afternoon New York time. I though pen this from across the seven seas (I am on vacation!!). Hope some of you find this useful.

Personal Regards,

Nitin Sethi, MD

Mind-body interventions: applications in neurology

A comprehensive review  on mind-body interventions and its application in various neurological disorders was recently published in Neurology. The authors Wahbeh, Elas and Oken searched Medline and PsychoInfo databases to identify clinical trials, reviews and published evidence on mind-body therapies and neurological diseases.

Meditation, relaxation, breathing exercises, yoga, tai-chi, qigong, hypnosis and biofeedback are some of the mind-body interventions that have been used in various neurological conditions like general pain, back and neck pain, carpel tunnel syndrome, headaches (migraine and tension), fibromyalgia, multiple sclerosis, epilepsy, neuromuscular diseases, stroke, falls with aging, Parkinson disease, stroke and attention deficit hyperactivity disorder (ADHD).

The authors do a good job in shifting through all the data to try to identify the effectiveness of mind-body interventions. As they point out in their discussion , many patients as many as 62% use complementary and alternative medicine therapies (CAM). Some with and many without the knowledge of their physicians. One of the reason why CAM therapies are popular is that they are relatively easy to implement, cheap (though many patients have to pay out of their pocket. Some insurance companies shall reimburse if you have a letter from your doctor) and more importantly as the authors point out it makes the patients feel empowered. They feel that they are in control of some of the decision making in their disease process and treatment. Moreover it gives a sense of general well being.

The authors righly point out that is difficult to scientifically judge whether these interventions are all effective. The reason for this is that many of the studies included small number of subjects and some of them did not have a control group. Moreover it is hard to blind these studies so as to avoid a placebo effect. Like suppose I want to study whether acupuncture is effective for lower back pain. One group I give acupuncture. Ideally I should have a control, a group which receives sham acupuncture so as to null the placebo effect. Now this is difficult to implement.

Th authors in their review conclude that there are several neurological conditions where the evidence in favor of mind-body therapies is quite strong such as migraine headaches. In other conditions the evidence is limited due to small clincial trials and inadequate control group.

It is reasonable to conclude that CAM therapies like yoga, tai-chi and qigong improve balance in the elderly and decrease the incidence of falls. Moreover they give a sense of well being and happiness. Meditation exercises whether it is mindfulness meditation, transcendental meditation or concentration meditation with the repetition of a word like Om or a mantra

“Hare Krishna Hare Krishna

Krishna Krishna Hare Hare 

Hare Rama Hare Rama

Rama Rama Hare Hare”

all help in relaxation and reducing stress. This may decrease blood pressure and reduce the incidence of strokes and heart attacks. Brain changes have been observes during meditation in EEG and imaging studies and there is evidence that these exercises have wide spread effects on the endocrine and immune systems as well neurotransmitters. Hatha yoga may help in improving mobility and balance and thus decreasing fall risk. As the authors point out righly Bikram yoga  which is carried out in very hot temperatures is likely not good for patients with MS, as it may worsen their weakness. This is called Uhthoff phenomena.

There is also some evidence to suggest benefits of these interventions in patients who have chronic lower back and neck pain, those with fibromyalgia, osteoarthritis as well as carpel tunnel syndrome (some studies suggest benefit while others do not).

My advise to patients who want to try out CAM therapies for various neurological conditions is to take their doctors into confidence. It is likely that some of these therapies when used along with allopathic medicines shall give added benefits and likely make you feel better. Like with any other therapy one must find a knowledgeable practitioner who knows what he or she is doing.

Then one can truly reap the benefits of these ancient therapies.

Personal Regards,

Nitin Sethi, MD

Stroke and nirvana: what is the connection

Stroke and nirvana: what is the connection

 

Nitin K Sethi, MD

 

        Comprehensive Epilepsy Center, Department of Neurology, NYP-Weill Cornell Medical Center, New York, NY (U.S.A.)

 

Address for Correspondence:

NK Sethi, MD

Comprehensive Epilepsy Center

Department of Neurology

NYP-Weill Cornell Medical Center

525 East 68th Street, York Avenue

New York, NY 10021

Fax: 212-746-8984

Email: sethinitinmd@hotmail.com

I just read this article in the New York times today titled ” A superhighway to Bliss” by Leslie Kaufman which talks about Dr. Jill Taylor a neuroscientist working at Harvard’s brain research center who experiences nirvana while she is suffering a stroke. She suffers a left parietal bleed and at the time when she is hemorrhaging into the brain, she experiences this amazing peace. The constant chatter that normally fills her brain stops, her perceptions change and she feels disconnected.

What would you ask all this has to do with nirvana. Nirvana by the way is the state where you attain the supreme bliss. In Hindu mythology we talk about nirvana and mosha. Mosha as in when you are free from the troubles of this world and one with God.  Well basically as the article goes on to mention that the right and left hemispheres of the brain have different functions. The dominant left hemisphere (in people who are right handed) houses ego, context and time logic. The right hemisphere on the other hand gives creativity and empathy. So in a way when your left hemisphere is shut down (as in Dr. Taylor’s) case by a hemorrhagic stroke, she experiences this peace and calmness because her ego is gone. The article later goes on to mention, that she has written a book about the same and now lives a more peaceful and spirtual life because she has learnt how to sidestep her left brain.

Hmmmmm I am not sure what to make of this and where I stand on this topic. Sensory disintregation may occur at the time of a stroke and patients have reported some very vivid experiences during the time of the stroke such as out of body experiences. Did Dr. Taylor suffer something like that during the time of the stroke. The fact she is a neuroscientist may have given the ability to better recognize her stroke as it was occuring.

In any case, parietal strokes especially when large can be devastating and not everyone has such a nice outcome as Dr. Taylor. The two hemispheres in the brain are closely interconnected and it is not possible to voluntary shut down one part of the brain. We can do it in the lab, by injecting a drug which shuts down one side of the brain such as amobarbital. This test is called WADA test and it would be interesting to note if anyone else has described reaching nirvana at the time of WADA testing.

The human brain is indeed like the wind and difficult to control. Thoughts are always racing through the brain some useful and others at time meaningless. Why you may ask are we always having thoughts in our head? Is there a way to make the brain empty of thoughts maybe for just a short time so that we can be totally in peace. Can the practice of yoga and meditation do that.

This brings me to the question I asked in my post on yoga and meditation: Does a meditative mind lead to a meditative brain?  Can by intense meditation, yoga or spirituality we slow down and stop these thoughts in our head?

I would appreciated all my readers thoughts about this.

Transient ischemic attacks or TIA’s

Let us talk about transient ischemic attacks or TIA’s here. What does it mean when your doctor tells you that you had a TIA?

TIA or transient ischemic attack as the name suggests means that one has an episode of transient ischemia to the brain. Kind of like a mini-stroke except that for it to be called a TIA, the neurological deficits should reverse completely. Let me explain this further. Suppose you have an episode of sudden weakness of the right side of the body (arm and leg) and at the same time, your speech is off. This presentation is mostly likely due to ischemia (lack of blood flow) in the left middle cerebral artery of the brain. Now this can act out in 2 ways. One you are recover completely, often within a few minutes to an hour at most. That means the ischemia was transient and that you are not left behind with any neurological deficits (no weakness and speech is back to normal). This would then be called a TIA involving the left middle cerebral artery.

The second possibility is that you do not recover at all, or do recover to some extent (after been treated in the hospital for acute stroke). Here the patient has stroked out. If you do an MRI of the brain, you shall see evidence of acute stroke. In a TIA, the imaging shall be normal as the recovery is complete.

So now that we understand what a TIA means, let us talk about the different types of TIA’s. One of the most common TIA is what we call transient monocular blindess or Amaurosis Fugax. This is a special type of TIA in which there is sudden lack of blood flow into the ophthalmic artery (branch of the internal carotid artery in the neck). As there is lack of blood flow in the artery which supplies the retina, patients notice sudden onset of loss of vision in one eye (remember I said monocular). Ususally they describe it as if a curtain suddenly descended in front of that eye. This monocular blindness lasts for a few seconds to minutes and then goes away.

One can have other types of TIA’s depending upon which blood vessel in the brain has a sudden episode of ischemia. So you have patients who present with history of transient weakness in an arm or leg, transient speech difficulties, transient numbness in an arm or leg, transient episode of dizziness or unsteady gait etc etc.

So are TIA’s important and do they need to be treated is the next question? Usually a TIA shall affect the patient and make him or her visit the ER. Some patients though may ignore the episode, since now they are back to normal and just go on with their lives.

A TIA is a warning sign for stroke. It usually is a sign that a stroke is imminent. The brain has suffered an episode of dysfunction even though transient. Here in lies the importance of recognizing a TIA and seeking medical attention for it. Studies have shown that major strokes may soon follow a TIA.

What to do if you have a TIA?

1) well first things first it is important to recognize a TIA and give it its due importance. If you are having stroke like symptoms call for help and dial 911 and be taken to the nearest hospital for evaluation. You do not know at the onset whether this is going to be a TIA and that you shall recover completely without any intervention or that you are going to stroke out. Remember time is brain, the more time you waste, the more likely you shall suffer damage to the brain from a stroke.

2) If you are having a TIA, it is likely that the symptoms shall have abated by the time you reach the ER. Well and good, as you rather have a TIA than a stroke.  When patient’s present to the ER with a TIA, doctors usually admit them for a thorough stroke evaluation. We have a unique opportunity to try to identify your risk factors for stroke and modify them, so that you do not have a future stroke. Your doctor may run many tests on your brain (MRI, carotid dopplers to look to see if your neck vessels are patent) as well as on your heart ( as some strokes and TIA’s come from the heart. Tests like holter monitor and ECHO).

We can also prescribe you medications to make your blood thin, medications like aspirin which may reduce the risk of a future stroke.

So remember to recognize a TIA and seek help promptly. A stroke prevented is a brain saved.

Dr. Sethi

Stroke

Stroke is one of the most common neurological conditions. Also called a cerebrovascular accident (CVA), it can have a devastating outcome. Just as you have a heart attack when the blood supply to the heart is compromised due to a clogged artery in the heart, stroke is similarly a brain attack and occurs when the blood supply to the brain gets compromised. The brain is richly supplied by blood vessels and does not tolerate ischemia (reduced blood supply) well.

There are different types of strokes and here I shall enumerate a few of them. Strokes can broadly be categorized under 2 headings:

1) Ischemic strokes ( when blood supply to the brain is compromised eg a clot in the artery supplying the brain shall cause an ischemic stroke).

2) Hemorrhagic strokes ( when a blood vessel in the brain ruptures, hemorrhage occurs into the surrounding brain structures causing a hemorrhagic stroke).

 

Ischemic strokes can be caused by several different kinds of disease processes and can be further classified either on the basis of the calibre of the blood vessel involved or on the basis of the pathogenic mechanism which caused the stroke.

On the basis of calibre of the blood vessel involved, strokes can be further classified as

1) Large vessel strokes: a big blood vessel in the brain gets blocked. Usually when the doctor refers to a large vessel stroke he means strokes involving large arteries such as the internal carotid artery (ICA), the middle cerebral artery (MCA), anterior cerebral artery (ACA) or the posterior cerebral artery (PCA).

 

2) Small vessel strokes: a small blood vessel in the brain gets blocked. Usually these are the penetrating arteries of the brain which supply the deeper parts of the brain.

Based on the mechanism/cause of ischemic strokes, we can classify strokes as:

1) Atherothrombotic : the stroke occurs due to atherothrombosis, the same mechanism which causes many of the heart attacks. The blood vessels of the brain become hardened and narrowed due to atherosclerosis: an inflammation of the arteries due to deposition of lipoproteins/fat and cholesterol . This deposition of lipoproteins give rise to what we commonly refer to as plaques. This most commonly occurs in people who have risk factors for both stroke and coronary artery disease namely diabetes, hypertension, high cholesterol, smokers etc.

2) Embolic: here a plaque may break off from its primary site such as the heart and travel up to the brain blocking off a brain vessel. Lots of things can embolize to the brain:

-cholesterol plaques

-fat embolism ( commonly seen after one has a long bone fracture. The long bones like tibia and femur are very rich in bone marrow which is rich in fat. When a fracture occurs rarely the fat may embolize via a blood vessel to the brain.

-air embolism ( strange though it may sound even a bubble of air can embolize to the brain and cause a stroke)

Embolic strokes can be of two types:

1) Cardioembolic : a clot embolizes from the heart to the brain.

2) Artery to artery embolic: a clot embolizes from a larger artery commonly the carotid artery in the neck to a small artery in the brain.

Hemorrhagic strokes: just as ischemic strokes, hemorrhagic strokes can also be of various types. Hemorrhagic strokes are usually classified on the basis of the compartment of the brain into which the bleeding occurs.

1) Bleeding can occur into the substance of the brain itself: this is called as primary intracranial hemorrhage (ICH)

2) Bleeding can occur in the subarachoid space of the brain: this is called sub-arachnoid hemorrhage (SAH). I shall be discussing this under a separate heading.

3) Bleeding can occur in either the epidural or subdural space: this is called epidural hematoma (EDH) and subdural hematoma (SDH) respectively.

 

Risk factors for stroke/ CVA

There are numerous risk factors for stroke. As both stroke and coronary artery disease involve blood vessels they share some common risk factors.

Risk factors can be divided into: modifiable and non-modifiable risk factors.

1) Non-modifiable risk factors include:

a) Age: strokes are more common in the older age groups. Strokes do occur in the young and even in children and infants but they have diffferent causes.

b) Sex: there is some sex difference in the incidence of strokes.

c) Race: hemorrhagic strokes are more commonly seen in Asians as compared to Caucasians.

d) Genetic causes: if you have a very strong family history of strokes or coronary artery disease ( example your father had a stroke, his father had a stroke and all at a relatively young age then you too have a high risk of having a stroke at some point in your life). Unfortunately the genes which impart this increased risk have still not been clearly delineated, so no one knows just how much is the risk. If bad cholesterol or high blood pressure and diabetes runs in your family and in you then your risk for strokes and heart attacks is increased.

 

As you may realise the above risk factors are non-modifiable, meaning there is precious little you can do to change them. You cannot stop aging, change your race or sex or modify the genes that you were born with !!! Not at this juncture at least. Maybe in the future science shall advance to the extent that we can modify these bad genes.

 

Modifiable risk factors:

There are numerous modifiable risk factors for strokes and CAD. I shall list them out as follows:

1) Hypertension: hypertension or high blood pressure (BP) is the number one modifiable risk factor for both strokes and heart attacks.  Hypertension has rightly  been called the Silent Killer. It usually does not cause any overt symptoms and people are unaware that they have a high blood pressure. At times vague complaints of headache and fatigue may make them seek medical attention where a blood pressure evaluation shall disclose that they are hypertensive. (hypertensive meaning one who has high BP).

2) Diabetes mellitus: diabetes mellitus (DM) too increases the risk of strokes and CAD especially when the blood sugar is uncontrolled and constantly elevated. People who have DM may not know that they have diabetes for a long time as initial signs and symptoms may be subtle. In the setting of uncontrolled blood sugar they may have complaints of polyuria ( too much and too frequent urination), polyphagia ( hungry and always eating, most of the diabetics are obese) and polydipsia ( feeling thirsty all the time). As the disease advances complications of diabetes emerge namely poor wound healing, frequent urinary tract infections, heart attacks, strokes, eye-problems (cataracts and retinal problems leading to impaired vision), nerve problems ( neuropathy) and kidney problems ( renal insufficiency sometimes requiring dialysis).

3) Smoking: people who smoke have a much higher risk of getting a heart attack or a brain attack. The toxins in cigarette smoke damage the lining of the blood vessels in both the heart and the brain.  No amount of smoke is good for the heart or the brain. One should quit completely to lower this risk of heart and brain attacks.

4) Sedentary life-style/ lack of exercise:  a sedentary life-style also predisposes to strokes and heart attacks. People who are obese especially those with central obesity ( fat around the tummy) have higher risk of strokes and heart attacks.

5) Hypercoaguable states: certain people have factors in their blood which make their blood more coaguable, meaning the blood clots more readily. Examples include patients who have diseases like lupus, sickle cell anemia etc.

6) Dyslipidemia or bad cholesterol:  as many of you know there are many types of cholesterol found in our bodies. Not all cholesterol is bad. People who have more bad cholesterol (increased low density lipoproteins, increased very low density lipoproteins) and low levels of good cholesterol (high density lipoproteins) have higher risk of strokes and heart attacks.

 

Treatment of stroke: before I talk about the treatment of stroke, I rather talk a bit about stroke prevention. Prevention is always better than cure. Stroke prevention involves modification of the risk factors for stroke. Smoking cessation is the key as smoking is an important risk factor for stroke. Smokers get atherosclerosis at an earlier age than non-smokers (their arteries get hardened). Smoking cessation may involve behavioral therapy as well as use of nicotine patches and gums. People who have hypertension should ensure that their hypertension is adequately treated. Nowdays we recommed aiming for blood pressures of 120/70 mm Hg or even less. There are many drugs out there for the effective treatment of high blood pressure. The same is true for diabetics and euglycemia (getting blood sugar as close to normal) is the goal. This may be achieved either by pills (oral hypoglycemic drugs) or with insulin. Recommendations are to reduce Hb A1C (also called glycosylated hemoglobin to below 7). The importance of regular physical exercise cannot be overstated. I would recommned some cardio-vascular exercise like brisk walking or jogging. This is good both for the brain as well as the heart. Diet too plays an important role in stroke and dietary modifications may be one way to reduce your risk for strokes and heart attacks. Eating a diet rich in fish oils, poly unsaturated fatty acids, green leafy vegetables and fruits helps to naturally lower your cholesterol down. Recently the benefits of cooking in olive oil have been emphasised.

 

Management of an acute stroke: