After a stroke: The expanding role of exercise in promoting recovery

Katherine Frey/THE WASHINGTON POST - Kris Brott, foreground, demonstrates an exercise that has helped her recover from a stroke. Beside her is Chris Spring, a Pilates instructor who offered to assist Brott with her workouts.

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Kris Brott was more amazed than alarmed when her tongue suddenly seemed to turn upside down in her mouth. She was in the office at Quince Orchard High School in Gaithersburg, dropping off a check for her son’s baseball team, when she suddenly found herself quite literally tongue-tied.

Her puzzlement gave way to panic when she reached her car and looked in the mirror. The left side of her face had collapsed. By the time she reached home, her left arm had gone numb. Soon she was dragging her left leg.

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It was March 15, 2010, the day before her 45th birthday. This couldn’t be happening, she thought. She was too young and much too fit. “I still kept thinking, ‘I’m not having a stroke,’ ” she recalled.

She was wrong. At the hospital, emergency room physicians cleared the clot from her brain, but the damage had been done. When Brott was left with little strength on her left side despite physical therapy, she faced a long, difficult future in a body compromised by a disease of the elderly — until she decided to take control of her own recovery by returning to the gym.

Researchers are learning that exercise can help younger stroke victims such as Brott regain function, even years after they are stricken. A widely cited 2011 study provides support for therapeutic approaches like the one Brott stumbled upon when she returned to the gym.

“The secret to recovery in stroke is to continue working on your balance, continue working on your upper extremities, continue working on your lower extremities,” said Pamela W. Duncan, a neurology professor at Wake Forest Baptist Medical Center in Winston-Salem, N.C., and co-leader of the Locomotor Experience Applied Post-Stroke (LEAPS) research project.

The LEAPS researchers had originally set out to determine whether supporting stroke victims in harnesses to help them walk on treadmills would improve mobility more effectively than structured physical therapy at home, assisted by a therapist.

But when they tested 408 stroke survivors, a large number for such a study, Duncan and her colleagues unexpectedly discovered that the harness and treadmill produced approximately the same results as the structured at-home therapy. Perhaps more interesting was another finding: A group of patients whose therapy was delayed for the purpose of comparison also showed marked improvement when their therapy began.

“No matter when you start an intense, progressive program, it works,” said Katherine J. Sullivan, a neuroscientist and an associate professor of physical therapy at the University of Southern California, who led the LEAPS study with Duncan.

This is good news for stroke survivors, because delays in rehabilitation are inevitable for some who must be stabilized medically before they can attempt even minimal exercise.

“Rehabilitation can have some impact even months to years after a stroke,” said Ralph Sacco, past president of the American Heart Association-American Stroke Association. “The brain can relearn and recover. Physical activity can open up some new pathways.”

Yet the length of formal rehabilitation is largely determined by medical insurance coverage, according to advocates who want longer programs for stroke survivors who need them. When rehab ends, a continued independent exercise program may help for some.

Middle-aged women and stroke

Brott’s case is not as uncommon as it may seem. Though they still comprise a tiny proportion of all people who have strokes, nearly 2 percent of women ages 35 to 54 reported suffering a stroke in the most recent National Health and Nutrition Examination Survey, which covered 1999 to 2004. That is up from just half of 1 percent in the same survey a decade earlier. The stroke rate for women in this age group has tripled, while the rate for men has remained the same.

No one knows why so many relatively young women are having strokes, but the obesity epidemic is the prime suspect. When USC neurologist Amytis Towfighi looked more closely at the national health survey data, she saw that the proportion of women with abdominal obesity had risen from 47 to 59 percent in a decade.

The 795,000 strokes that Americans suffer annually vary widely in severity and location in the brain, with effects that range from death to little or no impairment. Stroke is the fourth-leading cause of death in the United States; women tend to survive more often than men but are more likely to be disabled, according to Towfighi.

A tiny, Type A gym rat, Brott doesn’t let much get in her way for long. When she was unhappy with a contractor laying wood floors in her home, she fired him and installed them herself. Then she figured out how to put in lighting and did that, too.

Once a 3:57 marathon runner who switched to spin classes after an injury, she decided at her neurologist’s recommendation to return to the huge Sport & Health Club in the Rio shopping center in Gaithersburg, where she had worked out nearly every day before her stroke.

By chance, she met a rookie Pilates instructor, Chris Spring, who agreed to work with her. Neither woman had any background in medicine or rehabilitation.

“I said, rationally, if it’s a mind-body disconnect, let’s get the connection going again,” Spring said.

Spring decided to use the Reformer, the medieval-sounding platform that is the most basic equipment in many Pilates studios. Originally constructed out of available parts by Joseph Pilates while he was interned by the British during World War I, the device has evolved into a standard piece of gym equipment that fosters a total body workout using resistance springs.

At first, Brott had so little strength in her left hand that Spring had to lash it to the device’s straps with elastic hair bands. As Brott’s right side did the work, her left side went along for the ride. “She could think it, but her body wouldn’t obey her,” Spring said. “She could want to draw her arm back, but she couldn’t make it happen.”

The women met as often as six times a week, working Brott’s weak muscles again and again. At night, Spring did more research and devised additional exercises. Brott worked out for another hour at home.

They began to see progress in six to eight weeks. “She’d say, ‘Oh my God, I can feel my left deltoid.’ And we’d both cry,” Spring said. “And she’d say, ‘Oh my God, I can feel my left hand grip.’ And we’d both cry.”

After six months of workouts, Brott estimated that she regained nearly 95 percent of the ability she had before her stroke. There still are points of numbness along her left arm, but to see her work out is to observe a woman who appears to function normally.

At Spring’s urging, Brott did one more thing: She became a Pilates instructor and now teaches classes at Rio Sport & Health.

Another victim

Before her stroke at the age of 41, Leila Abedi liked to swim at the big gym near her Gaithersburg home. Now the best she can do is get into the pool to work her rigid right arm and the right leg she has dragged since that terrible day 14 months ago.

Though she understands everything, she can manage only a word or two of speech. During a conversation with a visitor in her living room, Abedi’s husband, Sasan, communicated with her by posing lists of possible answers to which she nodded, sighed or grunted in response.

Young sweethearts in their native Tehran, Leila and Sasan separated when Sasan went into the military. Leila eventually married another man, had a son, divorced and left the country with her child, living for a time in a refu­gee camp in the Netherlands.

Sasan, who moved to the United States 22 years ago, brought Leila here 12 years later and married her the next day, July 5. “So every year there are fireworks” for the couple’s anniversary, he said with a smile.

On Jan. 2, 2011, Sasan found Leila unresponsive on a couch in their home. At two local hospitals where Leila was examined, doctors weren’t convinced she was having a stroke and did not test for one for more than 24 hours, according to Sasan. By then, Leila had suffered more impairment, he said.

Like Brott, Leila Abedi has had speech, occupational and physical therapy, though with less success. She went back to Iran for three months in the hope that rehab in her native Farsi would improve her speech. And when she was ready, she went back to the Rio Sport & Health, where she used to swim.

There, someone mentioned a Pilates class where “the instructor is a stroke patient,” Sasan recalled.

Less than two years removed from her own life-altering crisis, Brott has gently tried to help Abedi through hers, supplementing Abedi’s extensive physical therapy with exercise. As Spring did with her, Brott slowly worked Abedi’s recalcitrant limbs, trying to reestablish the mind-body connection. It was slow going; Abedi’s deficits are larger than Brott’s were.

“Who would understand [stroke victims] better than I?” Brott said. “Who would understand their frustration?”

She recalled a moment during her own recovery when she was standing in a busy Target store, overwhelmed as everyone around her moved at normal speed. She felt frozen, glued to the floor.

“Everyone was just going, going, going. ‘I don’t fit in this world anymore,’ ” she recalled thinking. “ ‘I just want to go back to my world, where everything is safe.’

“Someone else who hadn’t had a stroke wouldn’t understand that.”

 
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