Highs, Lows, and Plateaus: A Path to Recovery from Stroke

Highs, Lows, and Plateaus: A Path to Recovery from Stroke

by Anne Burleigh Jacobs Pt Phd


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This book is a must read. It is a valuable resource for stroke survivors, anyone whose life has been affected by stroke, and health care professionals working in rehabilitation. While the focus may be on recovery from stroke, much of the information in this book could apply to traumatic brain and spinal cord injury.

Written in an easy to understand, conversational tone, complex topics are simplified and made meaningful through storytelling and analogies. What inspires hope is the potential for ongoing recovery. This book walks the reader along a path of recovery: from the initial injury, to the mechanisms for recovery, to the future of rehabilitation.

Dismissing the negative connotations of "plateau", this book provides hope and inspiration for continuum along the path of recovery. Each step along the path is supported by basic science, concepts of neuroplasticity, and the resilience of the human spirit.

Product Details

ISBN-13: 9781491862308
Publisher: AuthorHouse
Publication date: 03/13/2014
Pages: 120
Product dimensions: 6.00(w) x 9.00(h) x 0.44(d)
Age Range: 1 - 17 Years

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A path to recovery from stroke



Copyright © 2014 Anne Burleigh Jacobs, PT, PhD
All rights reserved.
ISBN: 978-1-4918-6231-5


What Is A Stroke?

This book focuses on the mechanisms of recovery from a stroke, but to understand recovery one needs a basic understanding of injury. Much of the information applies to other injuries of the central nervous system, including traumatic brain injury and spinal cord injury. In general, injury to the central nervous system involves a disruption of blood flow, inflammation, and damage to the cellular structure.

Stroke is the result of disrupted blood flow to the brain. The more technical term is Cerebral Vascular Accident (CVA): cerebral = brain, vascular = blood flow, accident = unexpected. The more attention-catching media term is Brain Attack – much like a Heart Attack. A heart attack occurs when blood flow to the heart is interrupted and the cells that are electrical in nature stop functioning. Likewise, a brain attack occurs when the blood flow to the brain is interrupted causing the cells that are electrical in nature to stop communicating. The symptoms of the brain attack (stroke) will depend on which pathway for blood flow is interrupted and thus the corresponding region of cells whose communication is compromised.

There are two main types of stroke:

Ischemic and Hemorrhagic.

With the ischemic stroke, there is actually a blockage in the blood vessel preventing the flow of blood past that point. A clot that forms in place (thrombosis) or a clot that has broken loose and traveled from some distant blood vessel (embolism) forms a blockage. Cells on the far side of the blockage are denied blood flow and begin to die.

With the hemorrhagic stroke, there is actually a bleeding vessel within the brain environment. The most common hemorrhagic causes include an Aneurysm, an ArterioVenous Malformation, and a Hematoma following a blow to the head. Blood is actually toxic to neurons (brain cells). Usually, neurons never come into direct contact with blood. Instead, a small helper cell called an astrocyte places one foot on a blood vessel and one foot on a brain cell and then oxygen and nutrition diffuse out of the blood vessel, through the astrocyte and to the brain cell. So, when there is a bleed in the brain environment, cells in direct contact with blood begin to die.

As neurons die, the cell walls collapse and the chemical content of the cell is released, poisoning other cells in the surrounding area. But, it is important to appreciate that not all of the cells in the area die. Brain cells are pretty clever. Recognizing that the brain environment has become a war zone, the surviving cells turn down their energy production and go silent ... waiting for the danger to pass.

That war zone is a mess – a zone of swelling, cellular debris, and chemical toxins.

Last winter, there was a terrible storm that moved through the mountains where we live. Trees were down everywhere and with them were downed power lines and phone lines. No Power, No Communication. Silence after the storm.

Neurons are electrical cells. They conduct a signal and communicate with other cells via a chemical-electrical cascade. When neurons die or go silent, they simply stop communicating. The goal of recovery is to either repair the downed lines of communication or build new lines of communication so that cells are able to receive and send messages again. Sometimes this happens quite quickly - almost spontaneously - sometimes it takes a long time and a lot of work, and sometimes, the barriers to recovery are just too great. It is very difficult to know which survivors will continue to recover and which have reached their limit. Individual determination, finances, the survivor's pre-stroke health, personality and environment are important components in their recovery.

~ Sometimes recovery means regaining past abilities and sometimes it means learning new ways. ~



Emergency Treatment of Stroke

I graduated with my bachelors' degree in Physical Therapy in 1985. At that time, there was not a lot that could be done in regards to the emergency treatment of stroke. By the time I earned my doctoral degree in Neuroscience and Physiology in 1995 progress was in the making. In February 1996, a clot-busting medication was approved, by the Federal Drug Administration, for the emergency treatment of stroke. This medication, tissue plasminogen activator (tPA) is able to dissolve a clot allowing blood flow to be restored to the brain, but it must be administered within only a few hours from the onset of the ischemic stroke. It doesn't work for treatment of hemorrhagic stroke. Remember, that type of stroke involves a ruptured blood vessel, not a clot or blockage. But, the introduction of tPA for emergency treatment of stroke opened the door to many recent advances in the treatment of stroke.

Advances in imaging and drug delivery have helped to lengthen the treatment window for using tPA. Clot-retrieval devices that mechanically reach into a blood vessel to remove the clot have recently come onto the treatment scene and have lengthened the treatment time window. Surgical advances have also been made in the treatment of hemorrhagic stroke.

In 2003, the Joint Commission, a nonprofit organization that accredits and certifies healthcare organizations, joined forces with the American Heart Association and American Stroke Association (AHA/ASA) to begin certification of Primary Stroke Centers (http://www. strokeassociation.org). These centers are certified to provide for emergency treatment of stroke. More than 900 hospitals nationwide have been certified. It may be worth knowing which hospitals in your area are certified.

In 2012 this accreditation process was expanded and the Joint Commission together with AHA/ASA began certification of comprehensive stroke centers. These centers are even more specialized having advanced treatment and surgical tools for the emergency management of stroke. Also, they have a team of rehabilitation professionals who specialize in treating patients following complicated strokes.

Recently, Telemedicine has been an exciting advancement in emergency treatment of stroke. This allows hospitals in even the most remote regions to have immediate access to top-notch, specialized neurologists who can guide the treatment protocol using tPA.

Eleven years ago, I knew a woman who had a stroke while enjoying a day boating on a lake in the Sierra Nevada Foothills. By the time she was transported to the local hospital and then transferred to a Primary Stroke Center that was three hours away, too much time had passed. The treatment window was closed and nothing could be done except to wait and see how bad the effects of the stroke were and then plan for rehabilitation. This year, that same small hospital in the Sierras is geared-up for telemedicine, which now may allow them to successfully treat that patient who years ago they could not.

Unfortunately, a low percentage of people having an ischemic stroke (due to clot) get to the hospital within the treatment window for using tPA. Community education is key to getting people to recognize the signs and symptoms of stroke and having enough confidence to act quickly. Community education about the warning signs as well as the risk factors for stroke also helps to lessen the fear that many stroke survivors live with daily – the fear that they will have another stroke.

The treatable risk factors include:

High Blood Pressure, High Cholesterol, Atrial Fibrillation, and Diabetes. Sometimes there are also injuries to the blood vessels themselves, which require medical attention.

The lifestyle-related risk factors include:

Tobacco use (smoking or chewing), Excessive alcohol consumption, and Obesity. The use of birth control pills, in addition to any of the other risk factors, also increases the risk for women.

Assuming a healthier lifestyle and working with your physician and a dietician is the first step in decreasing the risk factors associated with stroke.

The following chapter provides examples of the signs and symptoms of stroke. I encourage everyone to know these, because you may be the one to recognize someone else's stroke and seek emergency medical attention for them.

~ Time Lost is Brain Lost ~



Stroke Strikes AnyWhere, AnyTime

It is very important for everyone to recognize the signs of stroke, because stroke strikes anywhere, anytime, across age, ethnicity, and socio-economic groups. I have never known anyone who planned on having a stroke. But, I know a lot of people who survived with minimal deficit because someone else recognized the signs and sought help. Unfortunately, in my field of work, I also know a lot of people whose symptoms of stroke went unrecognized. Remember, according to U.S. national statistics, a low percentage of stroke victims get to the hospital in time for emergency intervention.

The odd thing about a stroke is that the person having a stroke often does not fully realize that anything is wrong. When asked if they are o.k. the person having the stroke quite often says they are fine or makes up a reason to explain their behavior. Remember, it is the brain that is under attack - and this is the same brain that is supposed to be identifying that something is wrong! A brain under attack is going to have to rely on someone else to identify the problem and seek help.

The stick-figure on the preceding page is used by the Pacific Stroke Association (formerly the Peninsula Stroke Association), based in Palo Alto, California (http://www. pacificstrokeassociation.org). It was drawn by a man, Sam Frank, who had a stroke while attending a meeting. A colleague knew something was wrong and called 911. Sam was successfully treated with tPA, the clot-busting drug approved by the FDA in 1996. This simple stick-figure, represents the array of signs and symptoms of stroke. Not everyone will present with the same set of symptoms, but in general it is advised "TWO OR MORE IN COMBINATION – CALL 911"

Headache – Lots of people have headaches, but this headache is often described as the "first or the worst." People report that the headache they had the day of their stroke was different than ones they had before; it was the first one like it. Also, they report it was the worst headache they had ever had. Remember, one or more of the other symptoms will accompany this headache.

Change in Vision – Any sudden change in vision is a warning sign that something is wrong. People will report that

• their vision grew blurry,

• they lost vision in one eye,

• a curtain fell over part of their field of sight

Sometimes stroke victims don't really lose part of their vision, but they lose the perception of vision – they can no longer decipher or understand what they see. For example, the red-octagonal sign at an intersection may appear to have some white letters or figures, but it holds no meaning. The stroke victim, may see it, but not understand that it is the familiar stop sign.

Speech – Any sudden change in the ability to speak or to comprehend language is a warning sign that something is wrong. The stroke victim may present with

• slurred speech,

• loss of speech,

• partial loss of speech with word finding problems,


• they may be able to speak, but it is all nonsense.

Weakness – This may present as weakness and loss of coordination of the face, hand, arm, or leg on one side of the body, OR it may be a generalized weakness and loss of coordination in both legs. Often, the stroke victim may fail to move a body part and not even be aware of it. For example, they may drag their leg when attempting to walk, be unable to lift their arm to turn off the water and instead use the other hand. They may smile or talk and not be aware that one side of the mouth is drooping.

Change in Sensation – This symptom often accompanies the weakness or loss of coordination. People have reported "that their leg was so heavy they couldn't move it," OR "that one hand felt like it was burning," OR "that their ankle felt like it was trapped in quicksand," OR "that one side of their body just went away."

Dizziness and Loss of Balance – Lots of people experience dizziness, so it is important to recognize that this is a sudden onset of dizziness that is NOT preceded by a sudden change in head position. This is a dizziness that just comes on without warning and is often accompanied by a loss of balance as well as the other symptoms.

It is really important for everyone to know these signs of stroke and feel confident enough to seek medical attention.

~ You may be saving someone else's life. ~

Let me give you a couple of real-life scenarios and you try to recognize the signs of the stroke:

A.B. was at work when he developed a severe headache. He asked a colleague for an aspirin but found he was unable to open the pill bottle he was given. His right hand just would not close tightly enough over the childproof cap. So, his colleague helped him to open the pill bottle. A.B. then went to the break room to get some water to take the pills. He had to hold the water glass with his left hand, and was embarrassed when a female colleague saw him dribble some water on his shirt. He decided to go home. On the way to his car, he stumbled and dropped the car keys. A woman in the parking lot picked up his keys for him, and asked if he was okay. A.B. did not reply. It was after he crashed his car on the way home that the paramedics determined that A.B. was having a stroke.

* * *

S.S. had finally scheduled time for lunch with friends. She had been so busy helping to plan her daughter's wedding that it was a welcomed break. S.S. was very talkative and having fun, but her friends thought it was odd that she did not eat the food on the left side of her plate. Her waiter noticed it also, and he also noticed that she was not lifting her left leg when she was walking from the restaurant and that she seemed confused when she bumped into the door on her way out. He would have thought she was drunk, but he had not served any alcohol at their table. If you were that waiter, what would you have done?

* * *

I.W. was at home when her husband knew something was wrong. She had just returned from the grocery store and was unloading the groceries. She was dropping everything and kept swearing. I.W. never swore. When her husband asked if she was all right, she replied "fine, fine, f**king fine". Then, I.W. went to bed to rest. Her husband went to check on her, did the FAST test then called 911.

* * *

The National Stroke Association (http://www.stroke. org) uses the acronym FAST as part of their community education to help people recognize the signs of stroke. The acronym stands for Face; Arms; Speech; Time – providing for a quick assessment of the warning signs of stroke and emphasizing the need to call 911 immediately if a stroke is suspected.

I remember once I was giving a lecture about the need to recognize the warning signs of stroke, when someone in the audience had a stroke! Yep, right then and there a woman in the audience displayed the warning signs and the person seated next to her recognized what was happening. Oddly enough, I was the one who was hesitant to call 911. I cannot really explain why. I think I was nervous about possibly being wrong and causing a huge embarrassment. But the signs were there – and 911 was called. The paramedics arrived quickly and the woman was transported to a hospital that provided emergency treatment for her stroke. Imagine the embarrassment I would have had to face, and the guilt, if we had not called 911.

The National Institutes of Health through the National Institute of Neurological Disorders and Stroke (NINDS) also strives to educate the public about the symptoms of stroke and provides information about ongoing research and clinical trials (http://www.ninds.nih.gov/disorders/ stroke.htm).

Community education about the warning signs and symptoms of stroke are the first line of attack in reducing the incidence and severity of stroke. With the multitude of resources available to learn more about the signs and symptoms of stroke, it is prudent to take the time to learn the signs. You may be the hero who seeks help for another.

~ Know Stroke. Know the Signs. Act in Time. ~



Excerpted from HIGHS, LOWS, AND PLATEAUS by ANNE BURLEIGH JACOBS, Stephen Adams. Copyright © 2014 Anne Burleigh Jacobs, PT, PhD. Excerpted by permission of AuthorHouse.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Table of Contents


Acknowledgements, vii,
Introduction to the Author, ix,
Preface, xi,
Chapter 1. What Is A Stroke?, 1,
Chapter 2. Emergency Treatment of Stroke, 5,
Chapter 3. Stroke Strikes AnyWhere, AnyTime, 9,
Chapter 4. The Not So Obvious Effects of Stroke, 15,
Chapter 5. History and the Plastic Brain, 23,
Chapter 6. Restoring Electrical Pathways, 29,
Chapter 7. "Plateau" Is Not A 4-Lettered Word, 47,
Chapter 8. Injury To The Brain and Then What, 53,
Chapter 9. Stages in the Continuum of Recovery, 63,
Chapter 10. Requirements For Learning and Plasticity, 79,
Chapter 11. Emerging Tools In Rehabilitation, 87,
Chapter 12. Simple Rules To Promote Improvement, 95,
Appendix. References and Recommended Reading, 97,
About the Author:, 105,

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