By JANE E. ALLEN
Los Angeles Times

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.

New and ongoing research suggests that stroke patients can continue to improve for far longer. But such achievement requires a different type of rehabilitation - one that’s more time-consuming, 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,” said Michael Weinrich, director of the National Center for Medical Rehabilitation Research in Bethesda, Md. The center funds researchers who are pushing the envelope of expectations for stroke patients.

The new approach, neuro-rehabilitation, relies on the brain’s ability to rebuild itself, to learn new tasks. 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.

Current treatment primarily teaches patients to compensate for their lost abilities by using their “good side” for daily activities like dressing, eating and cooking.

Jim Krakowski of Los Angeles knows the limitations of traditional treatment. He 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 cross 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,” said neurologist Dr. Bruce Dobkin, head of stroke rehabilitation at the University of California, Los Angeles. Medicare 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.

More than 700,000 Americans suffer strokes each year, and 170,000 die. Stroke is the third-leading cause of death, behind heart disease and cancer, and is the nation’s leading cause of disability. 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,” said physical therapist Pamela W. Duncan, director of Brooks Center for Rehabilitation Studies at the University of Florida. But 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 are trying to change that status quo.

The most promising techniques use treadmills to retrain patients in walking and devices that force patients to use weakened arms. 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. 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. 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 to unlock a door, push a model race car around a sharply curved track, pick up small paper clips and fasten them to a cardboard drink holder.

On a recent day a physical therapist clocked his time. On the ninth day of his 10-day training, he had halved his time at several tasks and was lifting his left arm higher. Dugan smiled. “I’m never going to give up. Never.”