Module 1 for stroke carers introduces what the word – stroke – refers to, what happens in a stroke event, types of stroke, and who are at risk.
At the end of this module, you will be able to answer the following questions if someone asks.
1.1. What is a stroke?
1.2. What happens in a stroke?
1.3. How does a stroke occur?: Types of stroke
1.4. What is a “mini-stroke”?
1.5. Who are at risk?
1.1. What is a stroke?
The term, “stroke” is a broad one; a more recent definition from the American Heart Association/ Stroke Association advocates use this term to cover cell death that occurs in the brain, spinal cord, and retina attributable to the interruption to the blood supply. According to this definition, the presence of symptoms or signs of more than 24 hours is not essential to use the term. And, on the other hand, the presence of reversible stroke-like symptoms more than 24 hours due to edema without interruption to the blood supply does not qualify for a stroke.
However, “Stroke” is a disease of the brain, not of the heart. Many believe, incorrectly, that it is a type of heart disease. Since it occurs suddenly, some call it a “brain attack”. Health professionals name the condition as “cerebrovascular disease”.
Stroke is the second leading cause of death and the third leading cause of disability in the world. As much as 70 percent of stroke events are thought to occur in low-middle income countries. On average, a stroke occurs 15 years earlier among people living in those countries. During the past four decades, stroke incidence among low-middle income countries has doubled while it has halved in high-income countries1.
A stroke occurs as a result of brain cell death due to an interruption of blood supply to a part/s of the brain. We will discuss this in module 2.
Stroke warning signs are easy to detect. The common ones are drooping one eyelid, inability or difficulty of raising one or both arms, and slurred speech; there are more. We will discuss these in module 3.
However, a stroke can also occur without any observable changes.
Stroke results in a range of disabilities of the affected person and at least half of these disabilities persist permanently for life, if not treated early. It exerts an enormous burden not only on the person affected but the whole family, and the society. We will discuss various kinds of disabilities in detail and what we can do to rehabilitate those in Part II of this course.
1.2. What happens in a stroke?
A stroke cuts off blood supply to a part of the brain. (You can learn more about the brain by joining the “journeys to the brain” series). Within minutes, the neuron cells in the affected area begin to die at a rate of 32,000 per each passing second. In terms of minutes, the number amounts to about two million neuron cells per minute2.
The only way to save the rest of the cells threatened with death is to restore the interrupted blood supply as soon as possible. This can only be done in a hospital with adequate facilities.
1.3. Types of stroke
A stroke usually occurs either due to a block in a supply route or a burst of the supply route’s wall.
1.3.1. Ischemic stroke
Ischemic stroke occurs due to a block by a blood clot inside the supply route. The extent of the damage depends on where the clot clogs the blood supply system inside the brain. If a clot is a bigger one, it clogs a larger artery and blocks the blood supply to a larger area of the brain. If the clot is a smaller one, it may travel as far higher up as possible until it clogs a smaller branch of a smaller artery.
How a blood clot forms
A roughened wall of an artery triggers blood clot formation. The roughening begins with fat deposition at one place of the wall. Then, it hardens with calcium and cholesterol deposits. The process continues slowly but surely forming a plaque there. This thickening narrows the lumen and roughens the surface. Plaque build-up can occur anywhere; however, strokes are commonly associated with plaque build-up in the neck vessels – carotid arteries as shown in Figure 1.
The following video clip from the British Heart Foundation explains simply how arterial thickening occurs and the factors that facilitate the process.
A clot can even originate inside the heart particularly among those with heart problems and travel into the brain.
In the US, about 80 percent of all strokes are in this nature according to the National Institute of Neurological Disorders and Stroke3. In low-middle income countries, this percentage is about 66 percent1.
1.3.2. Hemorrhagic stroke
When a stroke occurs due to a burst of the vessel wall, we call it a “hemorrhagic stroke” (Figure 2). As a result, blood seeps out of the vessel, and oxygen and food supply to neurons interrupt. The bleeding exerts pressure on the area causing more damage.
However, there is another 5-10 percent of people who develop a stroke due to an unknown reason4.
1.4. What is a “mini-stroke” TIA (Transient Ischemic Attack)?
In this situation, the stroke signs and symptoms last less than 24 hours; most often, less than an hour. Hence, it is also called “Transient Ischemic Attack” (TIA). What happens here is that the clot that blocks the supply route disappears after a brief time.
However, it is a dire warning; it will certainly return as a full-blown stroke, often within the first week after the TIA, if not treated5.
Therefore, a mini-stroke should also be considered as a medical emergency.
In the following video clip, Professor Peter Rothwell explains why we should a mini-stroke also as a medical emergency.
However, if the effects last more than 24 hours, it is considered a stroke. Ideally, anyone who experience a mini-stroke should not drive or operate a machinery for a month. In some countries it is the law.
1.5. Who are at high-risk?
Some are at higher risk for stroke. We can reduce the risk by modifying some risk factors while others are non-modifiable. The source of the following list is the National Institute of Neurological Disorders and Stroke3.
Non-modifiable risk factors
- Age: The risk doubles every passing decade from 55 to 85. However, it can also occur in childhood6.
- Sex: Men are at higher risk in young and middle age. In older ages, however, the risk is equal.
- Ethnicity: some ethnic groups are at higher risk; for example, African-Americans and Hispanics experience stroke events more than Caucasians.
- Family history
Modifiable risk factors
There are some risk factors that we can reduce the risk. Those are as follows;
- High Blood Pressure: This is one of the most potent risk factors we can easily modify.
- High cholesterol
- Cigarette smoking: This raises the ischemic stroke risk by two-fold and hemorrhagic stroke risk by four-fold.
- Physical inactivity and obesity
- Johnson, W., Onuma, O., Owolabi, M. & Sachdev, S. Stroke (2016): a global response is needed. Bulletin of the World Health Organization 94, 634–634A, https://doi.org/10.2471/BLT.16.181636.
- Jeffrey L. Saver (2006): “Time is Brain”: Quantified; Stroke Journal. 2006;37(1): 263-266.
- National Institute of Neurological Disorders and Stroke (NINDS): Basic facts: preventing stroke; NIH; 2020. Accessed on September 16, 2020.
- Donkor E.S. (2018): Stroke in the 21st Century; Stroke Res Treat.: published online.
- British Medical Best Practice; accessed on September 20, 2020.
- Vrudhula A, Zhao J, Liu RToo Young to Have a Stroke?—a Global Health CrisisStroke and Vascular Neurology 2019;4:doi: 10.1136/svn-2019-00029.
Have you thought about this? About the detrimental effects of prolonged bed rest? This post is about that.
A little bit of history about bed rest research
Researchers say that bed rest was considered as a treatment strategy in the 19th century. This view was beginning to change at the turning to the 20th century.
In 1947, Dr. R.A.J. Asher wrote an article to the British Medical Journal about “Dangers of going to bed”. His article was meant for physicians: ” we should think twice before ordering our patients to bed and realize that beneath the comfort of blanket there lurks a host of formidable dangers”.
Since then, more evidence has been accumulating. In 1999, a group of researchers reviewed 39-bed rest trials published in The Lancet. The conclusion: bed rest did not improve the outcome significantly; rather they reported nine situations with worsening outcomes.
However, the campaign is ongoing. For example, if you visit the website of the American Academy of Nursing, you can read the “Don’t Statement”:
In fact, The problem has received attention from several countries. It has led to a campaign named, “End PJ paralysis”.
End PJ (Pyjama) paralysis
End PJ paralysis is a global movement: https://endpjparalysis.org/
The following is a poster that is aimed at addressing this problem. We can find a series of similar educational tools to reduce the detrimental effects of prolonged bed rest.
Let us dive into our bodies to find out what happens when we take prolonged bed rest.
What happens inside our body during a prolonged bed rest?
All our body mechanisms are set to function best when standing upright – and, to sleep only about eight hours. If we prolong our bed rest time for more than 24 hours, the body begins to re-set all the systems to face the new challenges. Certainly, it will. And, it will result in a series of detrimental effects of prolonged bed rest.
Let us jump into this journey of exploring the “detrimental effects of prolonged bed rest”.
Prolonged bed rest’s detrimental effects on the heart and our blood circulation
In an upright position, most of our blood circulates below the heart level. Veins bring up the returning blood with all waste products produced by cells including carbon dioxide. The valves in veins and muscles support veins to do the job.
In contrast, in a lying down position, blood slowly moves to the abdomen, lower back, and lungs from the legs. The new situation exerts pressure on the heart. To relieve the pressure, the body initiates mechanisms to remove a certain amount of water from our blood through kidneys. The aim is to reduce the burden – preload – on heart output. Not only that, but the prolonged bed rest also reduces red blood cell mass too to reduce our blood’s oxygen-carrying capacity.
If the bed rest continues as long as 6 weeks, research has shown that the heart muscles can get atrophied. If the bed rest continues for 20 days, the heart output can reduce by 25 percent according to Kristin J. Stumpfle and Daniel G. Drury.
These adjustments cause problems; one is to increase the resting heart rate; another is the postural hypotension in which we feel dizzy when we attempt to either sit on the bed or stand. It can occur even after 24 hours of strict bed rest.
Another interesting adjustment occurs in our venous blood collection system. It begins to pool blood at our deep veins. As a result, the risk of developing blood clots increases leading to deep vein thrombosis. And, the formed blood clots can dislodge, travel all the way up to lungs, and stuck there. This can result in pulmonary embolism, always a fatal situation.
Prolonged bed rest’s detrimental effects on our muscles
Very much similar to the heart and blood circulation mechanism, our muscles also work best when we stand upright against gravity. In a prolonged bed rest, with time, they begin to shorten and then remove some of its muscle fibers. It invariably loses muscle mass and subsequently its strength. Research shows that we can lose muscle strength by 6 – 40 percent within 4 – 6 weeks of complete bed rest. More recently, a group of researchers from Johns Hopkins found that each passing day in the ICU lowers muscle strength by 3- 11 percent a day over the ensuing months and may even extend to years.
As expected the most affected muscles are the ones that work against gravity”: The “anti-gravity” muscles. Those are the muscles that help to raise the foot at the ankle joint (plantar flexors), those in the thighs and arms (quadriceps and hamstrings), those in the buttocks, calves, lower back, abdomen, and the neck. In some muscles such as those in calves, thighs, and feet, we can readily see the wasting; however, in other muscles, we cannot readily see. Research shows that the process of wasting begins as early as on the fifth day and reaches its peak in the second week of bed rest.
Effects on joints
Muscles are attached to joints through tendons and ligaments. And, joints are covered by some cartilage. Because of non-use, fibers in tendons and ligaments become shortened. Surrounding connecting tissues turn rigid due to the addition of collagen. The result? the development of almost permanent contractures that freeze joint movements. Research shows that the appearance of collagen fiber can be observed as early as on the sixth day of complete bed rest.
These changes occur in all joints. But, it is most pronounced in the hip, knee, and ankle joints.
Effects on bones
As in every part of our body, bones also respond negatively to bed rest. It begins to weaken with time; its building block – calcium – starts appearing in our urine within a few days of bed rest. It also increases the risk of forming kidney stones and urine infections. To make matters worse, calcium absorption in the intestine also decreases.
Research reveals that the bones in our legs and lower back are the worst affected.
Effects on the kidneys and bladder
Due to non-use of bones, its building block, calcium, beings to drain into urine. During the process, the chances of forming stones inside kidneys and the bladder rises. Furthermore, due to urine rentioninside the bladder the chances of urine infection als rises.
Effects on the skin
The effects of prolonged bed rest on the skin particularly the skin over bony prominence are two-fold; shear and friction damage the superficial parts of the skin while the pressure interrupts the deep tissue functions. It includes underlying muscles too.
Prolonged bed rest due to the pressure it exerts on the skin over bony prominences occludes the smallest blood carriers – capillaries – blocking the blood supply to the skin and its surrounding tissues. This sudden attack deprives living cells of oxygen and nutrient supply. The situation will lead to cell death.
Experts say that the critical duration of pressure that requires developing a pressure injury can vary from 30 minutes to 4 hours. This variation depends on underlying diseases that affect small blood supply vessels including the smallest – capillaries.
Shearing, in addition to the direct external pressure, contributes to skin damage. Shearing refers to lateral displacement of the skin due to traction over the surface. Moreover, moisture too worsens the situation by softening the skin layers.
Not only the external pressure, but shearing and friction on the skin damage the skin also. It deprives the skin cells and underlying tissues of its oxygen and nutrition for their survival, It can result in devastating bedsore. Once the process sets in, it can become a slippery slope. The most common 5 sites that pressure ulcers occur are the heel, ankle, bony prominences over the sides of the hip, sacral area, and skin over the sitting bones in the buttocks.
In fact, the detrimental effects of prolonged bed rest manifest all over the body.
Can we create neurons from another cell type? Yes!. The red-colored cells you see in the above image are neurons that were originally mice glial cells. NIH researchers have converted those into neurons using gene therapy.
Furthermore, these new neurons, they have demonstrated, can do the lost neurons’ job!.
You can read more about this amazing story on the NIH Director’s blog.
We know about neurons; do we know enough about Glial cells?
In fact, glial cells outnumber neurons. And, they are very close allies of neurons. If they do not exist, neurons cannot exist.
Types of glial cells
There are three types of glial cells: Astrocytes, Microglia, and Oligodentrocytes. The diagram below illustrates them.
As you can see, they look like stars and in contact with both neurons and the cells of the supply routes’ walls; in this case, the smallest branches of it – the capillaries. They also provide structural support to synapses. They play a crucial role in a stroke; strangely both hero and villain roles. Their members who reside as neighbors to the attacked area quickly undergo both structural and functional changes; they proliferate and form a fence. This separates the dead from the living, very much similar to the “crime scene” tapes.
This group scavenges dead cells and attack pathogens (disease-causing microbes). Their job is to maintain a healthy environment in the brain.
This group produces myelin that sheaths around axons of neurons. The myelin sheaths act as insulators that help send electrical current-based information faster.
Now, it is obvious that if they do not their job, there is no point in having neurons.
This is a special group. They act as scaffolds for baby neurons and guide them to migrate to their final destinations.
Global stroke care begs urgent attention, particularly in low-middle income countries. Every year, about 15 million face a stroke event in the world. Of them, about 5 million die while another 5 million become disable permanently. Almost 70 percent of stroke events occur in low-middle income countries. Alarmingly, while the new cases per 100,000 declined by half in high-income countries during the past decade, it doubled in low-middle income countries (Johnson et al., 2016).
More importantly, stroke occurs mostly at peak of one’s life.
Although vast improvements have occurred in stroke care in the world during the past decade,, these advances have not reached to low-middle income countries.
However, according to Walter Johnson and his colleagues, significant differences between high-income and low-middle income countries exist; that more stroke due to bleeding in low-middle income countries than high-income countries (34 percent versus 9 percent); that more survivors in low-middle income countries die within 3 years than high-income countries (84 percent versus 16 percent).
Surely the quality of care should also be remarkably different. For example, the absence of CT scan facility to differentiate strokes due to bleeding from a blood clot affect the intervention strategy.
A well coordinated global action is necessary as highlighted by the WHO experts.
How early someone who experienced a stroke event needs to sit on the bed if the individual has no either medical reasons not do so or severe disability?
It needs to be done as early as possible, even within 24 hours after a stroke for better recovery, according to the American Heart Association and the American Stroke Association.
However, sitting on the bed has to be followed up with intermittent standing and later with well-coordinated therapeutic exercise sessions.
This recommendation appears in their detailed statement published in the Stroke journal in 2014. It is because research shows early mobility improves chances of earlier walking ability and functional recovery.
The above findings came from a powerful randomized controlled study.
About the study
A research team compared assigned 71 stroke patients to two groups. Their mean age was 74.7. Their blood pressure, heart rate, oxygen saturation, and temperature were monitored. Among those who were safer to sit, one group received the usual standard care. and, the other group were mobilised early with a follow-up of intensive moblisation at regular inervals. Then their performance was compared on one primary outcome: the number of days required to walk 50 meters unassisted. They found that the intervention group returned to unassisted walking significantly faster than the standard intervention group (p=0.032; 3.5 median days versus 7 median days). Moreover, the other functional outcomes as measured by the Barthel index was better at 3 months in the intervention group.
The above study appeared in the Stroke journal in 2010.
However, there is a catch here. Starting physical activities early alone is not enough; it needs to be done consistently according to the above statement. This is the most difficult part.
Exercise and physical activities become effective if those are done consistently.Stroke Journal, 2014
Challenges in implementing these findings
Research reveals that although many who experience a stroke event can do exercises, they choose not to do. As a result, with time, not only their ability to walk but the ability to carry out daily activities also declines. This is because, with time, their heart-lung fitness too deteriorates.
Many factors contribute to this unfortunate situation; lack of knowledge, system inefficiency, and inadequate emphasis by healthcare professionals are the main reasons.
How to improve early mobility after a stroke
The experts recommend starting a planned exercise program as soon as the person is medically stable. The following are the specific recommendations from the American Health and Stroke associations;
The goal here is to regain or exceed pre-stroke level activity level as soon as and as much as possible. This should be started at the hospital and continued at home once discharged. The continuity is the key here for the success.
The critical principles here are;
- Maintaining the progressive task difficulty
- Functional practice
- Inclusion of aerobic (heart-lung) and strengthening exercises
The modes of adhering to above principles are;
- Treadmill exercises: Research has shown that aerobic treadmill exercise as early as within 6 days up to 6 months after stroke improves heart-lung fitness and walking distance.
- Cycling ergo-meter
- Recumbent stepper
- Chest-deep water
- Functional exercises
It is critical for the patient to develop the skills and confidence for eventual self-management of physical activity and an exercise training program.
It is critical for the patient to develop the skills and confidence for self-management of physical activity and an exercise training program.Stroke Journal, 2014: The statement from the American Heart and Stroke Associations
Experts recommend everyone to undergo graded exercise testing with ECG monitoring prior to the start of a graded exercise program. However, if the physician decides that screening for fitness is not possible due to lack of facilities, they further suggest not delaying the exercising but to tailor a program in order to suit the patient’s capability.
Due to lack of accessibility to graded exercise testing with ECG monitoring facility, experts recommend use of near-best simple test – “six minutes walk test”.
It is so critical to start a movement as early as possible; that is the key message here. For those who cannot do the exercise ECG testing, that should not be an excuse for exercise program; the recommendation is to initiate a lower-intensity one.
Whenever the prescribed exercise ECG testing is not done, a lower-intensity exercise program should be started.Stroke journal, 2014; the statement from the American Heart and Stroke Associations
About 85 percent of those who experience a stroke will have some sort of weakness in one or both of their upper limbs. This post discusses recommended methods on how to improve upper limb weakness.
A stroke occurs as a result of an interruption to the blood supply to a part of the brain that controls body movements and sensory inputs from body parts. There are two types of strokes: ischemic and hemorrhagic. Although some of the damage is permanent, still some can be recovered with specific exercises.
Evidence shows that “high-intensity, repetitive, task-specific practice” clearly improves motor recovery after a stroke event. However, the practices to regain lost functions of arms are different from legs’. Let us look at how best practice guidelines translate this evidence into recommendations for practice.
The Canadian stroke best practice guidelines published in 2019 provides the following recommendations to improve the function of the upper limbs.
Both the principles cited below are recommended for all those who experienced a stroke event less and more than six months.
- Create activities that are meaningful, engaging, repetitive, progressively adaptable, task, specific, goal-oriented.
- Create activities of daily living, that encourage the use of the affected limb.
Specific treatment methods
We need to be knowledgeable and creative to use these methods because the selection of method/s depends on the function affected.
Strong evidence from a Cochrane review exists that exercise for the affected arm is more effective than both arms. The Canadian stroke best practice guidelines also do not recommend both arm training when one arm is affected.
Recommended exercise/treatment methods
- Range of motion (ROM) exercises (passive and active-assisted)
- Mental imagery
- Functional electrical stimulation for the wrist and forearm muscles to reduce motor impairment and improve function
- Constraint-induced movement therapy for those who at least 20 degrees of active wrist extension and 10 degrees of active finger extension, with minimal sensory deficits and normal cognition
- Mirror therapy as an adjunct for those with very severe paresis
How do we know that these methods are effective?
A large number of research has demonstrated the effectiveness of the exercises. I will mention here one important study.
J. Leipert and colleagues mapped the cortical areas of the brain’s both sides of 13 individuals who were living with a stroke for more than six months. They found that the area of the affected side was significantly smaller than the area of the non-affected side. After subjecting them for 12-days of constraint-induced movement therapy, they re-mapped the same areas. Then, they found that those areas of the affected side were significantly enlarged. They published these findings in the Stroke journal in 2001.
Interventions with no evidence
It is also important for us to know the treatment methods with no sufficient evidence to date. According to a Cochrane review published in 2015, these are as follows;
- Music therapy
- Repetitive trans cranial magnetic stimulation
- Electrical stimulation
A guideline resource for exercise providers
The Ontario Stroke Network provides a useful guideline for community-based exercise providers; here is the link.
This glossary covers the terms used in the promotion of physical fitness. it includes the terms, physical activity, exercise, and types of exercises. The proper understanding of these terms and concepts are critically important in improving care for those living with a stroke.
All guidelines recommend for anyone living with a stroke should consult a physician and undergo medical screening to decide the suitability of exercises and range of motions.
Physical fitness refers to a situation in which someone can do their expected physical activities – activities of daily living, leisure – without undue fatigue (Saunders et al. 2016). When physical fitness is declining, the range of physical activities including Activities of Daily Living (ADL) will become increasingly difficult and vice versa.
The concept entails a set of attributes. It includes the ability to carry out the activities of daily living with vigor and alertness, without undue fatigue, and with ample energy to enjoy leisure-time activities and to meet unforeseen emergencies (Carl J Caspersen and colleagues).
Physical fitness includes the following five components:
- Heart and lung (cardiorespiratory) fitness: another name for this term is “endurance” which refers to the ability to do physical activities for an extended period than usual.
- Muscle strength: this refers to the ability of a certain muscle or a muscle group to exert certain force such as pushing, pulling, or lifting.
- Muscle power; refers to the ability to do single powerful action or a movement.
- Balance; refers to the ability to maintain balance and posture while moving or stationary.
- Range of motion (flexibility); this refers to the ability to do all movements around a joint.
- Body composition; refers to the relative amount of fat or fat-free mass.
Physical activity is defined as any bodily movement produced by skeletal muscles that result in energy expenditure (Carl J Caspersen and colleagues).
Physical activities can either be planned or unplanned. Exercise refers to planned physical activities.
Exercise refers to a sub-set of physical activity that involves planned, structured, and repetitive bodily movement that is done to maintain or improve one or more components of physical fitness (CDC US). These should be done with the purpose of improving physical fitness. For example, some may carry out their job-related or household physical activities with the aim of spending energy. Those activities are considered exercise (Carl J Caspersen and colleagues).
Light- moderate physical activities:
These activities include moderately-paced or leisurely walking or bicycling, slow swimming or dancing, and simple gardening (CDC).
Vigorous physical activities
These activities include fast walking, fast bicycling, jogging, strenuous swimming or sports, aerobic dance, or strenuous gardening (CDC)
Vigorous physical activities: These activities might include fast walking, fast bicycling, jogging, strenuous swimming or sports play, vigorous aerobic dance, or strenuous gardening.
These activities include strenuous muscular contractions such as weight lifting, resistance training, push-ups, sit-ups, etc (CDC).
Leisure-time physical activities; exercise, sports, or any other activity done during leisure time.
Types of physical fitness (exercise) training
- Heart-lung (cardio-respiratory) programs: to improve heart and lung fitness
- Resistance training programs: to improve muscle strength and muscle power
- Flexibility (stretching) training programs
- Balance maintenance training programs
- Mixed training programs: a combination of the above two types
Mode of training:
This refers to the methods employed for the type of training; for heart-lung training, it could be either walking, running, or cycling. It could be stationary too with or without an instrument/machine.
Dose of training:
The dose of training refers to the amount of training (the program length – number of weeks or months, duration of a session, and the intensity (amount of work or effort).
This refers to a prescription that includes mode, type, and a dose of the exercise recommended.
“Journeys to the brain” venture on a series of short trips that explore the brain. The posts dive into discoverers’ expeditions. The project is aimed at broadening the readers’ knowledge about the human brain.
The journeys that have ventured to date:
- Brain covers:1-journeys to the brain
- Brain surface:2-journeys to the brain
- Two little humans:3-journeys to the bran
- Brain’s blood flow:4-journeys to the brain
- Types of strokes;5-journeys to the brain
- Brain’s collaterals:6-journeys to the brain
- “Time is brain”:7-journeys to the brain
- Neuron forest:8-journeys to the brain
- Neurons:9-journeys to the brain
- Broca’s speech area:10-journeys to the brain
- Broca’s aphasia:11-journeys to the brain
- Wernicke’s aphasia:12-journeys to the brain
- Fighting the stroke:13-journeys to the brain
I am inviting all stroke carers to join with this project.
The “stroke carers’ photovoice project” requests you to submit your photos using this link: https://www.instagram.com/photovoiceforstrokecarers/.
You can use your camera phone – with regard to your carers’ life. It can include photos that depict your emotions, challenges, methods of caring as well as your innovative best practices created by yourselves.
So, your contribution is fairly simple: take a quick photo, write something according to the SHOWeD technique (you will find in this post later), and post it.
Research has shown that this photovoice technique brings immense value and meaning to your life and others who are and will be in a similar position as you.
What is photo voice?
Photovoice is a qualitative research method. The participants take photos that represent their own experience about a subject of interest, write a short narrative following a set of five standard questions (the SHOWeD technique), and later, they come together to discuss and exhibit.
More recently, the method is used for online projects too. Following this tradition, we propose a “stroke carers’ photovoice project”.
What is “SHOWeD” technique?
The “SHOWeD” is an acronym. You are requested to write something as responses to the following questions with regard to the photos you submit. The “SHOWeD” refers to;
- S = What do you See in this photo?
- H = What is Happening in this photo?
- O = How does it relate to Our lives?
- We = Why does this situation or concern exist?
- D = What can we Do about it?
Some example photos that you can post are below.
Submitting photos are surely carry some important ethical practices. Based on past research, We request to adhere the following rules.
- The photographer owns the copyright. As a result, you can decide either to add your name whatever you choose – either a real name or any other name – to the photo and the narrative you write.
- Make every genuine effort to ensure the privacy of you and your loved one whom you are taking care of.
- Ontario Stroke Network: Post-stroke community-based exercise guidelines
- Fitness and mobility exercise (FAME) program for stroke:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3266302/
- FAME program for chronic stroke:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226792/
- Manual for basic exercises for stroke: https://www.oatext.com/manual-of-basic-physiotherapeutic-exercises-for-family-and-caregivers-of-stroke-patients.php#gsc.tab=0
- Physical activity and exercises recommendations for stroke:https://www.ahajournals.org/doi/pdf/10.1161/STR.0000000000000022
- At-home exercises for stroke survivors:https://strokeconnection.strokeassociation.org/Spring-2019/At-home-Exercises-for-Stroke-Survivors/
Canadian best practices guidelines
- Management of upper extremity following stroke: https://www.strokebestpractices.ca/recommendations/stroke-rehabilitation/management-of-the-upper-extremity-following-stroke
- Range of motion exercises for shoulder, arm, and hand: https://www.strokebestpractices.ca/recommendations/stroke-rehabilitation/range-of-motion-and-spasticity-in-the-shoulder-arm-and-hand
If you have more guidelines, manuals, and other resources related to exercises for stroke, please send us.
- Clinical consequences of stroke: http://www.ebrsr.com/sites/default/files/Chapter%201_Clinical%20Consequences_0.pdf
- Recovery and organized care: http://www.ebrsr.com/sites/default/files/EBRSR%20Handbook%20Chapter%202_Brain%20Reorganization%2C%20Recovery%20and%20Organized%20Care_2020.pdf
- Mobility rehabilitation: http://www.ebrsr.com/sites/default/files/Chapter%203_Lower%20Extremity_2020_ML.pdf
- upper extremity rehabilitation: http://www.ebrsr.com/sites/default/files/EBRSR%20Handbook%20Chapter%204_Upper%20Extremity%20Post%20Stroke_ML.pdf
- Cognitive rehabilitation: http://www.ebrsr.com/sites/default/files/EBRSR%20Handbook%20Chapter%205_Rehab%20of%20Cognitive%20Impairment.pdf
- Medical complications post-stroke: http://www.ebrsr.com/sites/default/files/EBRSR%20Handbook%20Chapter%206_Medical%20Complications.pdf
- Depression and community re-integration: http://www.ebrsr.com/sites/default/files/EBRSR%20Handbook%20Chapter%207_Depression%20and%20Community%20Reintegration_2020_ML.pdf
- Important clinical studies in stroke rehabilitation: http://www.ebrsr.com/sites/default/files/2013-working-copy-of-the-most-influential-studies_jan14-2014.pdf
- Post-stroke rehab fact sheet: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Post-Stroke-Rehabilitation-Fact-Sheet
- For physiotherapists:http://courses.strokengine.ca/