By Dietrich W. Miesler, MA, CMT
Originally published in Massage & Bodywork magazine, April/May 2000.
Stroke is one of the sneaky adversaries that snoops around members of the over-60 set, often pouncing when least expected. It can strike the nice old gentleman as he sits on a park bench feeding the pigeons or it may fell the executive bent over his putter, trying to sink the ball in the 18th hole in hopes of ending another golf outing triumphantly. A stroke can wipe out the lifelong athlete in the midst of that big senior meet.
While the occurrence of stroke is usually sudden, the outcomes are oftentimes far-reaching, permanent and devastating. With prompt treatment and a multidisciplinary approach to rehabilitation, long-term, adverse effects from stroke may be minimized. In this two-part discussion of stroke, we’ll look to understand what stroke is, who is at risk, what are the complications, what role massage plays in stroke rehabilitation, and the massage techniques used for this unique and primarily geriatric population.
Overview of Stroke Physiology
A stroke, or cerebrovascular accident (CVA), is an interruption of blood flow to a specific part of the brain. The exact location of the stroke determines the damage that occurs to the nervous system. There are two basic types of stroke: brain hemorrhage and brain ischemia. In the case of brain hemorrhage, there are two subdivisions: subarachnoid hemorrhage and intracerebral hemorrhage.
Subarachnoid hemorrhage means there is bleeding into the spaces around the brain. A collection of blood between the brain and cranium can cause pressure injury to the sensitive brain tissue, because the blood cannot swell outward against the cranium; instead it pushes inward against normal brain tissue.
Intracerebral hemorrhage means there is bleeding directly within the brain tissue. In similar fashion, there is brain injury due to pressure from a collection of blood within the tissue and irritation of free blood to the brain tissue. Brain hemorrhage accounts for approximately 20 percent of the total number of strokes, with subarachnoid and intracerebral evenly distributed.
The most common type of stroke, accounting for 80 percent of CVAs, is caused by brain ischemia which means injury to brain tissue due to inadequate blood supply, and thereby nutrients, to the brain. Brain ischemia has four main causes: atherostenosis which causes a decrease in blood flow due to narrowing in the major arteries feeding the brain, such as the carotids or vertebrals; occlusion of small penetrating arteries deep within the brain; embolism, which is a traveling blood clot usually arising from the heart or great vessels; and hypoperfusion or hypotensive shock from poor cardiac output or general systemic failure. The incidence of brain ischemia increases with age because of the increasing prevalence of cardiac disease, hypertension, dysrhythmias (e.g., atrial fibrillation), diabetes and age-related cerebrovascular changes.
Transient ischemic attack (TIA) is a term introduced in the 1950s that refers to what is now commonly called mini-strokes. Some of the more common causes are thought to be microemboli or microvascular spasm. In either event, the tissue is transiently affected by reduced blood supply and symptoms are temporary. Like with stroke, the symptoms vary depending on the area of the brain involved, and what that area of the brain controls. TIAs are considered precursors or warning signs of the potential for future stroke, and should be evaluated by a physician.
Who is at Risk for a Stroke?
Stroke seems to have a somewhat random approach, although it is well-documented that lifestyle and behavioral choices play a big part. Some of the contributing factors to stroke are high blood pressure, smoking, high cholesterol, peripheral vascular disease, coronary artery disease, and blood clotting disorders. People with heart disease and diabetes have an increased risk for stroke because they oftentimes have several of the noted contributing factors. Some of the behaviors which contribute to cardiovascular disease and diabetes are smoking, high fat/calorie diets, lack of exercise, excess stress, alcohol consumption and sedentary lifestyles, to mention a few.
Neuromuscular Complications of Stroke
Every stroke is unique and the extent of damage to the body is determined by the location of the stroke in the brain. That is, the resulting deficits correspond to whatever that particular area in the brain controls, such as speech, movement, memory, cognition, etc. Sometimes these deficits are permanent and sometimes they can be reversed by initiating immediate therapy. Other times, the brain finds circuitous routes that establish an alternative connection. Research has demonstrated that brain cells can send out dendrites that can grow to one inch in length over a year, to find re-connections. And who knows? Recall the claim that we only use 10 percent of our brain. Perhaps that leaves 90 percent on standby. In other words, rehabilitation is not an exact science and the body is built for survival, ready to accommodate to its needs.
One peculiarity of the nervous system is that what affects one side of the brain results in contralateral response, so that a left-sided stroke will affect the right side of the body and a right-sided stroke will affect the left side of the body. As noted earlier, the deficits correspond to the functions the injured area of the brain controls. For example, a left-sided stroke also frequently results in speech/language comprehension difficulty because the speech center, named Broca’s area, is on the left side of the brain. Language deficits can frequently be improved with speech therapy. The first few months after the stroke, however, the patient is often agonizingly frustrated because of the inability to speak.
Stroke-induced brain injury in the right hemisphere affects the left side of the body and may disturb other functions within specific areas. Take for example the story of the great 20th century composer Maurice Ravel. He suffered a right-sided stroke and lost the concept of music completely because the nerves responsible for transmitting the sense for music are on the right side. It’s amazing though, how accommodating the brain is during childhood. Literature suggests that children who suffer left-sided brain injury transfer the functions of Broca’s area to the right side and learn speech — with all its intricacies — at the same rate as their uninjured peers.
Stroke frequently results in some degree of paralysis and or paresthesia (numbness, tingling, change in sensation). There are two main types of paralysis: flaccid paralysis (FP) and spastic paralysis (SP). With flaccid paralysis there is no nerve impulse transmitted down the limbs and thus muscles are unable to react. Flaccid paralysis causes the limbs to wither and hang lifelessly. This can contribute to shoulder strain and subluxation as the arm hangs heavy with no shoulder-joint muscle tone.
Spastic paralysis, on the other hand, does not mean the muscles are out of commission, but rather that they respond without control. Spastic paralysis can lead to painful and crippling contractions because the flexors are the stronger muscles.
This is seen most profoundly in those with a long-standing history of stroke. They have foreshortened tendons, which in time facilitates ossification of the joints, particularly in the knee, elbow and wrist. With this, the fingers are usually also curled tight, the thumb laying firmly across the middle and ring fingers. The same holds true for the flexor muscles in the legs; however, the contractures are usually not so pronounced because the extensor muscles are longer.
Except in cases where the day-to-day care is unable to work with the individual sufficiently, you may find patients who become fixed in the fetal position. This is a frequent sight in long-term nursing/convalescent home situations. These patients also tend to lie on their paralyzed side. These folks should be regularly repositioned, every two hours, to reduce contractures and prevent skin ulcers from pressure sores.
Pressure sores that break down into open sore ulcers are very painful and difficult to heal. These patients are also at an increased risk for blood clot formation due to prolonged immobility. This is an important point to remember when considering massage on a debilitated, immobile stroke patient.
In Part 2, we’ll look at the basis for massage therapy with stroke clients and the approach to take for massaging the client with stroke history.