Interview with CBT specialists: Rehabilitation process post stroke

Jānis Grants, a psychology doctor and brain injury rehabilitation specialist, begins the interview by explaining the complexity of stroke rehabilitation process. “It is very complex and difficult, not only for the stroke patient but for the whole family. There are several changes that happen very rapidly. One day a person is perfectly able to function, communicate with others, and the next day they are without these functions.” In this article, read an interview between Latvia’s leading professionals in the field Janis Grants and Agnese Orupe, a cognitive behavioral therapist, who talk about the rehabilitation process post stroke, what is to be expected, how a stroke occurs and how the different types of stroke manifest.

Rehabilitation process post stroke: Introduction

Agnese and Jānis both describe the main changes that occur to a stroke survivor. Janis mentions that these changes manifest in different ways: “One of them is with a person’s cognitive abilities. Then, language ability, the ability to think rationally. Behavior certainly changes. Before stroke one is able to do almost everything, post stroke they are limited due to their physical abilities. Emotions, the ability to maintain relationships change. These are some of the most significant changes post stroke.”

Janis continues about what should be done if there’s a stroke survivor in the family: “I think many families don’t really know what to do. They lack the information and support.” He mentions that stroke survivors and their families often obtain a negative perspective towards recovery because of what doctors and medical professionals tell them. “Of course, a negative outcome can occur if there isn’t a proper rehabilitation intervention. Yet with a proper stroke rehabilitation program, very good recovery results can be achieved.” Agnese sums up that most importantly the stroke survivor should follow their according rehabilitation program and consult with medical professionals and doctors. In case a stroke survivor doesn’t have a prescribed rehabilitation program, Vigo can help with its structured exercise plan. “Most importantly you should exercise daily, exactly as instructed, even if it’s very difficult,” Agnese emphasizes. Jānis mentions that a stroke survivor will experience difficulties doing various things and also lacks motivation. Therefore support from loved ones is very important.

Brain neuroplasticity: What is a stroke?

Agnese and Jānis talks about how a stroke occurs. Agnese explains that a brain injury occurs during a stroke: “There are two options – either a blood vessel clogs, as a result not enough blood flow occurs. Or the vessel bursts, and a haemorrhage in the brain occurs. Unfortunately these injuries are irreversible, unless the stroke is not very mild. And the more extensive the injury, the more affected the ability to function, the body and the emotional system.” But in this case, brain neuroplasticity helps. Jānis explains what brain neuroplasticity is.

“There are very important changes that occur in the brain, brain activity and cells. Let’s say, the injured brain cells won’t be able to perform those same functions they used to. However, the brain can restructure itself such that other parts of the brain take over those same functions that the affected part of the brain used to perform.” Jānis emphasizes that the brain neuroplasticity process is very much dependent on how diligently the rehabilitation program is followed. If a stroke survivor doesn’t follow the program and doesn’t perform the necessary exercises that promote brain neuroplasticity and stimulation, then the link between the active brain cells and affected body parts won’t be formed. “If there isn’t a lot of activity, no improvements will be seen. This new “conversation” in the brain won’t be formed, and unfortunately the stroke survivor will become disabled,” reveals Jānis.

Agnese says that a rehabilitation program needs to be started as soon as possible. As soon as the doctors allow to begin the rehabilitation process after the acute phase, it should be done. “Why is that so important? If time passes, some months or even a year, then the chance to reprogram the brain will be greatly reduced. Therefore, the optimal time to do so will be during the first few months. A lot should be done in the first year. Progress can occur later as well, but it won’t be as obvious and vast,” says Jānis. The patient will have more permanent damage, and the condition won’t improve as rapidly anymore. “Problem is that often times people lack the energy, they don’t know what to do, how to do it and what is the right amount. And it is important that clear instructions are given, that for example Vigo provides. Support from loved ones that can help maintain the motivation and positive spirit is crucial as well,” says Jānis. Agnese sums up that involvement from relatives is very important, both to perform the physical exercises and emotionally, such that the stroke survivor has a positive outlook towards their recovery. “Because the brain neuroplasticity basically promises us that there can be improvement. And this improvement can be significant.”

Types of stroke and after effects

Agnese and Jānis talk about the different types of stroke. “So, what we know when this brain injury occurs, different parts of our brains are responsible for different functions. And depending on where the brain injury occurred, one function or the other will be affected – either the ability to talk, the emotional system, etc.” Both specialists describe the different types of stroke and their typical after effects. Jānis mentions there are three main types of stroke. One of them is when a stroke occurs in the right side of the brain. That is when the left side of the body won’t work as it previously did. He mentions the most typical signs for this type of stroke: “There will be muscle weakness, muscle activity will be affected. Paralysis could also occur when the right part of the brain is affected. There could also be problems with focusing. A person might not be able to recognize things, they may feel confused. This type of injury could also cause changes in emotions.” He also mentions that the person can seem lethargic, could be overcome by inadequate emotions.

Jānis describes the second type of stroke, when the left part of the brain is injured. In this case the right side of the body will be affected. There will be weakness in the right arm and leg, could also be paralysis. “And that is the difference, how severely the arm and the leg will be affected. The important part about injury in the left side of the brain is that language is severely affected. Those can be difficulties talking, understanding language, different types of aphasia. That is the hardest part because the person can no longer communicate,” says Janis. He emphasizes that this is usually the most difficult part for a stroke survivor – to lose the language and speech abilities. And it requires hard work to regain these functions. It is possible that language ability won’t return the same way it was before. Both specialists mention that there are different types of speech impairments that can occur. Agnese says: “A stroke survivor may understand what they are being told, but they cannot express themselves.” Janis mentions: “Or the contrary – they may be able to talk and express words, but it makes no sense and others are unable to understand what they are trying to say.” He continues: “Or it could be that the stroke survivor is spoken to in their mother language, but it may seem foreign to them.”

Janis describes the third type of stroke which occurs in the brain stem: “With this type there are significant problems, because the most basic “ingredients” are affected. Those that we don’t even think of daily – breathing, heart function. As well as coordination, the ability to keep your balance.” He mentions that this type of stroke survivor will experience impairments in muscle activity, and won’t be able to use them like before. Difficulties are in that cognitive abilities are very good in this case. The stroke survivor is able to perceive and understand information well, however physically they look incapable. Agnese mentions that double vision may occur: “The person is ready to do things, however they cannot manage to navigate the space since the coordination is greatly affected. Which is a big problem when a person wants to exercise.” Loss of balance creates the risk of falling which can cause more injury to the stroke survivor.

The pace and intensity of stroke rehabilitation

Both specialists talk about the pace and intensity of the rehabilitation, how fast the stroke survivor can begin the rehabilitation process and what families can expect. “As we mentioned before, it is important to begin rehabilitation as soon as possible. A person has suffered a major injury, and their ability to mobilize their energy and fully work on the rehabilitation exercises will be very limited at first. They will be very weak.” Janis says that initially exercises should be performed very carefully, in small intervals. Someone who is physically stronger can help out. Because strokes differ in their intensity, the pace for the exercises will differ too: “It is very important to notice how capable the person is, how much energy they have. And simply take small breaks to relax,” explains Jānis. He mentions that loved ones should encourage the stroke survivor, give praise and express their care in different ways. “You can bring them tea, a snack, and then continue with exercising once more. And every day, many hours a day, in the same manner. You can work a few minutes, then take a break, then increase intervals gradually. And continue with this kind of routine,” Jānis suggests.

Agnese explains that it is important to create a daily regimen for the stroke survivor. “What doctors often mention in hospitals is that stroke survivors often have a reversed daily regimen. They sleep during the day and want to exercise at night, when everyone else in the household is asleep. This wouldn’t be a good routine, especially at home – when the family wants to relax, the stroke survivor is finally ready to exercise. That is why a daily regimen is very important,” she explains. Jānis adds: “Why is it important to be active at day and sleep at night? We have our natural rest/activity rhythm. We are awake during the day such that we can get energy from the sunlight.” He suggests holding on to a specific daily regimen – wake up at 7:00-8:00 AM and go to sleep at 9:00-11:00 PM. He explains why such a daily routine is important: “A routine helps calm people and give them the structure they need. So in the morning it could be breakfast, a cup of tea or coffee, personal hygiene. Then could be some time to perform work, for entertainment or a hobby. The intervals shouldn’t be too long.” It is important to pay attention to how much the stroke survivor is able to do, and when he is no longer able to perform the necessary exercises as successfully. Jānis mentions that exercises should be performed when the stroke survivor still has the energy: “It is important to understand that post stroke a person gets stronger progressively and starts recovering. You don’t regress post stroke.” He mentions that a stroke survivor’s condition stabilizes with time, progresses with exercising by following the rehabilitation program.

Pace of recovery post stroke

Both specialists talk about the pace of recovery and when some improvements can be observed. Jānis mentions: “If you think it will happen tomorrow, you will be disappointed. The recovery process from stroke is very slow compared to what we are used to. It will take time. If the rehabilitation program is followed consistently, then step by step the situation will improve.” Jānis explains that the process is long, it lasts several years, and in some cases can last 5-10 years. “But if the person continues with the exercises, do what they have been shown and what they have learned. They will continuously improve little by little. The problem is that we are used to working a little, then stopping and hoping everything will be fine,” says Jānis. He emphasizes that it is important not to discontinue the rehabilitation process, keep up with the exercises, otherwise the progress will stop. He mentions that families need to understand that their support will be needed for many years. “It won’t happen that after a few months of exercising consistently you will be able to relax. Therefore it is also important that family members come up with their own routines for this situation, and have patience. “They should switch roles, relax at times, because it will be very demanding and stressful to support a person with a major injury like this,” Jānis admits. Agnese adds: “Returning back to the metaphor about a child – the greater the brain injury, the smaller the “child”. And the more years they will need to recover, the more support system they will need.”

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