Stroke therapy sets its sights higher, farther
Hundreds of thousands of Americans survive strokes each year only to find they have trouble walking, talking or working, dependent on others for the most basic tasks.
Many patients with weakness or paralysis receive some therapy in a rehabilitation hospital or nursing home; others get it on an outpatient basis. But such treatment continues only while they show marked improvement -- usually six months at most. Most private and government insurance programs then provide for a wheelchair or cane, if necessary, and leave patients to manage as best they can. The progress often stops.
It might not have to be that way. New and ongoing research suggests that stroke patients can continue to improve for far longer, making greater gains and returning to productive lives. But such achievement requires a different type of rehabilitation -- one that’s more time-consuming, more demanding and much more expensive than the conventional approach.
“I don’t think there is any hard limit on how long after a stroke people can continue to recover,” says Michael Weinrich, director of the National Center for Medical Rehabilitation Research in Bethesda, Md. Part of the National Institutes of Health, the center funds researchers who are pushing the envelope of expectations for stroke patients.
The new approach, called neuro-rehabilitation, relies on the brain’s ability to rebuild itself, to learn new tasks. Adding to evidence of the brain’s plasticity, neuroscientists and physical therapists are finding that repetitive, challenging and individualized therapy can rewire the brain and improve stroke patients’ ability to move, put words together and articulate them clearly -- not just months after their attack, but even years later.
Most current treatment, on the other hand, primarily teaches patients to compensate for their lost abilities by using their “good side” for daily activities like dressing, eating and cooking. It’s often not enough for people accustomed to independence.
Jim Krakowski of Los Angeles knows well the limitations of traditional treatment. The former legislative analyst for the city was left partially paralyzed by a stroke four years ago at age 49. Conventional physical and occupational therapy helped him walk again, relying on a cane and a brace, but at a pace of 1 mph, he could hardly get across intersections before lights changed. Although convinced he could do better, Krakowski had exhausted the therapy his health plan would provide.
“The standard for what is an acceptable level of function is too low,” says neurologist Dr. Bruce Dobkin, head of stroke rehabilitation at UCLA. Medicare, for example, considers therapy successful if stroke survivors can walk 150 feet. But they may be incapable of climbing stairs or hills, they may have little endurance and they may be forced to use a brace or a cane. “We need to have ways that we can get more people who are really impaired functioning better,” Dobkin adds.
More than 700,000 Americans suffer strokes each year, and 170,000 die. The majority of strokes are caused by clots that cut off blood flow through the brain; others, called hemorrhagic strokes, occur when a blood vessel bursts inside the brain.
Stroke is the third leading cause of death, behind heart disease and cancer, and is the nation’s leading cause of disability. The American Heart Assn. estimates that the cost of stroke-related medical care and disability, including lost productivity, will be $51 billion this year. With the aging of the population and the increasing incidence of two major stroke risks -- obesity and diabetes -- longtime declines in stroke rates may reverse, experts say.
“Most people have a very nihilistic view of stroke. They think of Grandma living in a nursing home,” says physical therapist Pamela W. Duncan, director of Brooks Center for Rehabilitation Studies at the University of Florida. But the reality is that strokes occur at any age and most patients return home with “sometimes mild deficits that really do limit them and impair their quality of life.”
Experimental therapies, based on a growing understanding of the brain, are trying to change that status quo.
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Promising programs
The most promising techniques use treadmills to retrain patients in walking and devices that force patients to use weakened arms. Both can be appropriate depending on the quantity of surviving brain cells and the location of the damage.
In January 2001, Krakowski entered one of Dobkin’s pilot studies to retrain the muscles of his weakened leg. He underwent grueling sessions on a specialized treadmill, strapped into an overhead harness that took some of the weight off his legs, as physical therapists guided his bad ankle and knee and braced his hips.
After 12 sessions, he had increased his pace from 1 mph to 1.4 mph. Functional magnetic resonance imaging showed he was recruiting healthy regions of his brain’s motor cortex typically associated with learning new skills. After 30 sessions, he was walking at 1.7 mph. (Most people walk about 3 mph.) Muscle tests showed he’d increased strength and control of his leg. Additional brain scans showed, somewhat surprisingly, that he was now using the brain region healthy people use to control foot movement -- a region damaged by his stroke.
“It’s neurologically fascinating what’s going on,” said Katherine J. Sullivan, a physical therapist and neurology researcher who worked with Krakowski at UCLA before moving to USC. She noted that he has retained the improvements he got from the training two years ago.
Sullivan says that up to 80% of stroke patients could benefit from this type of intense retraining of stricken muscles and the nerves that control them.
Vernell Dugan, 52, is participating in a federally sponsored study of constraint-induced therapy, which also helps reteach the muscles and brain. For 6 1/2 hours a day, his right hand is covered by a special mitt, forcing him to use his impaired left arm for a variety of challenging tasks: unlocking a door, pushing a model race car around a sharply curved track, picking up small paperclips and fastening them to a cardboard drink holder.
On a recent day at a USC rehabilitation building, physical therapist Michelle Prettyman clocked his time and called out improvements. On this ninth day of his 10-day training, he had halved his time at several tasks and was lifting his left arm higher.
Dugan cracked a smile. “I’m never going to give up. Never.”
Most patients don’t have that option. Krakowski’s and Dugan’s gains come from the kind of repetitive therapy most stroke patients can’t get.
The University of Florida’s Duncan has studied the gap between stroke patients’ potential for recovery and the limited therapy they receive. It comes down to money.
USC’s private physical therapy practice charges paying patients (those who don’t qualify for clinical trials) $3,500 for the 65 hours of constraint-induced therapy, while similar programs elsewhere in the country are charging up to $13,000 for the most severely affected patients, said Carolee J. Winstein, a USC associate professor of biokinesiology and physical therapy. Patients without insurance coverage typically pay $100 an hour for 12 to 24 sessions of treadmill training, for a total cost of $1,200 to $2,400, Sullivan said.
Insurers might pay for such programs if they saw long-term savings -- fewer hospital stays, fewer nursing home admissions, fewer falls.
Dr. Michael Farber, a policy consultant to Medi-Cal, said the state’s health program for the poor currently provides what is considered standard therapy for strokes. When researchers can provide solid data demonstrating the usefulness of the new techniques, Medi-Cal might begin paying for them, he added.
Some scientists are experimenting with ways to more economically deliver neuro-rehabilitation. At MIT and at the Veterans Affairs Medical Center in Palo Alto, robots rather than therapists manipulate weakened arms in constraint-induced therapy. At the Rehabilitation Institute of Chicago, a Swiss-made robot called a Lokomat guides paralyzed legs and can do the work of therapists during bodyweight-assisted treadmill training. Elsewhere, research engineers are devising computer systems that use speech recognition to help patients with speech deficits. Others are creating virtual-reality systems, such as gloves linked to computers that conduct hand therapy.
No one has established “the optimal timing, intensity and duration of rehabilitation interventions for stroke,” says Weinrich. Although patients in rehab hospitals get three hours of daily therapy under a rule that began with Medicare and has been adopted by most health insurers, it may not be the right dose for everyone.
UCLA’s Dobkin is using brain scans to measure patients’ responses to intensive physical and speech therapy and to see if there’s a limit to improvement.
“As long as we can keep causing the brain to reorganize with treatment and show that runs parallel with improvements in function, we will keep pushing it until we stop seeing those changes,” he said.
Many experts predict that the best results will come from combining repetitive therapies with medications that bathe the brain in chemicals thought to enhance learning and brain function. Duke University doctors, for example, are trying to find the optimum time during therapy to give the stimulant dextroamphetamine to get greater improvements in movement. Rehabilitation Institute of Chicago researchers are giving bromocriptine (Parlodel), which is commonly used to help Parkinson’s disease patients, to help stroke patients go further with their speech training.
Dr. Mary Ellen Michel, a program director for stroke and traumatic brain injury at the National Institute of Neurological Disorders and Stroke, put the new outlook about stroke rehabilitation this way: “I don’t think you give up on the brain.”
