Physical Changes

A stroke survivor is likely to experience many physical changes, including:

• Changes in Swallowing
• Changes in Communication
• Changes in Movement
• Changes in Vision and Perception
• Changes in Bladder and Bowel Habits

Changes in Swallowing

Dysphagia

Any problem or difficulty with swallowing. This may be an oral or pharyngeal problem.

Symptoms include throat clearing, coughing, choking, multiple swallows with each bite or sip, loss of food from mouth during meal times, complaints of feeling food is “stuck” in the throat, pain during swallowing, wet vocal quality, dehydration, weight loss and temperature spike.

Aspiration

Entrance of food or liquid into the patient’s airway and infiltration into the lungs.

Studies have shown that 60 percent of patients with dysphagia are silent aspirators, showing no overt signs or symptoms of aspiration. Video oropharyngeal swallow study is a swallow assessment completed in the radiology
department. The patient is given bites and sips of different consistencies of barium. The radiologist and speech pathologist actually see the swallowing mechanism and make recommendations based on results.

Treatment/compensatory techniques:

• Patients to be upright 90 degrees for meals
• Small bites or sips
• Tongue or finger sweeps through mouth to clear pocketing
• Verbal cues to “tongue sweep” or tactile pressure cues to the patient’s cheek
• Checking and cleaning the patient’s mouth after each meal
• Patient to remain upright for 30 minutes after meals (to clear oral or pharyngeal residue)
• Alternate solid bites and liquid sips to clear pocketing in the mouth or residue in the throat
• Swallowing multiple times per bite or sip
• Thickening liquids to slow the rate of travel to the throat
• Oral motor or pharyngeal exercises given by speech therapist
• Thermal stimulation given by speech therapist
• VitalStim therapy given by speech therapist

Oral care is an important part of the equation for patients with dysphagia and should be performed after all meals or more as indicated by staff. Ice chips, ice cream and Jell-O are considered thin liquids.

Changes in Communication

Dysarthria

Dysarthria is an impairment of motor control for speech caused by weakness, paralysis, slowness, lack of coordination or sensory loss in the muscle groups responsible for speech.

Symptoms include:

• “Slurred” speech
• Speaking softly or barely able to whisper
• Slow rate of speech
• Rapid rate of speech with a “mumbling” quality
• Limited tongue, lip and jaw movement
• Abnormal intonation (rhythm) when speaking
• Changes in vocal quality (“nasal” speech or sounding “stuffy”)
• Hoarseness
• Breathiness
• Drooling or poor control of saliva
• Chewing and swallowing difficulty

Treatment:
Treatment depends on the cause, type and severity of the symptoms. A speech-language pathologist works with the individual to improve communication abilities. Goals may include slowing the rate of speech; improving breath support so the person can speak more loudly; muscle-strengthening exercises; increasing mouth, tongue and lip movement; or improving articulation so that speech is clearer.

The speech-language pathologist can also help the person’s caregivers or family learn to adapt the environment so that they can understand the person better and teach compensatory strategies to enhance communication.

In cases of severe dysarthria, it may be impossible for the person to speak intelligibly; an alternative means of communication may be needed. These range from using simple gestures or alphabet boards to more sophisticated electronic or computer-based equipment. If chewing and swallowing problems exist, the speech-language pathologist can address these areas as well.

Tips for the Listener:

• Control the communication environment by reducing distractions.
• Pay attention to the patient and watch them as they talk.
• Be honest and let the patient know when you have difficulty understanding them.
• Repeat the part of the message that you understood so that the patient does not have to repeat the entire message.
• If you’re unable to understand the message after repeated attempts, ask yes-or-no questions or have the patient write the message out for you.
• Encourage one word at a time with severe dysarthria.
• Cue the patient to “slow down” and “over-exaggerate” each word.
• Limit conversation when patient is extremely tired or fatigued.
• Encourage patient to use gestures or pointing with speech to convey message.

Apraxia

Apraxia is an impairment of motor planning for the movements for speech so that the voluntary control for speech is disrupted.

It’s characterized by problems sequencing the sounds in syllables and words. It varies in severity depending on the nature of the damage to the nervous system. People with apraxia know what words they want to say, but their brains have difficulty coordinating the muscle movements necessary to say those words. They may say something completely different, even nonsensical. For example, a person may try to say “kitchen,” but it may come out “bipem.” The person will recognize the error and try again. Sometimes they’ll get it right or say something else entirely. This can frustrate the person.

Signs of Apraxia:

• Difficulty imitating speech sounds
• Possible difficulty imitating non-speech movements, such as sticking out their tongue (oral apraxia)
• Groping for sounds
• In severe cases, an inability to produce sound at all
• Inconsistent errors
• Slow rate of speech
• Somewhat preserved ability to produce “automatic speech,” such as greetings like “How are you?”
• Can occur in conjunction with dysarthria (muscle weakness affecting speech production) or aphasia (language difficulties related to neurological damage)

Treatment:
A speech-language pathologist works with people with apraxia to improve speech abilities and overall communication skills. The muscles of speech often need to be retrained to produce sounds correctly and sequence sounds into words. This occurs through exercises designed to allow the person to repeat sounds over and over and practice correct mouth movements for sounds. The person with apraxia may need to slow their speech rate down or work on pacing their speech so they can produce all of the sounds necessary for their message. In severe cases, alternative means of communication may be necessary, such as the use of simple gestures or more sophisticated
electronic equipment.

Aphasia

Aphasia is the partial or total loss of the ability to articulate ideas or comprehend spoken or written language, resulting from damage to the brain caused by injury or disease. It most commonly affects the left side of the brain where the language center is located.

Signs of Aphasia:

• Difficulty understanding spoken words and following a conversation
• Difficulty expressing words or ideas verbally
• An inability to name objects or to recognize the written or spoken names of objects; this condition is known as anomia.
• Difficulty expressing ideas in writing
• Difficulty with reading comprehension
• Difficulty performing mathematical calculation
• Use of jargon or nonsense words
• Persistent repetition of certain words or phrases; this condition is referred to as perseveration.

Strategies to Help a Person with Aphasia:

• When speaking, make sure the patient is looking at you.
• Use simple, brief words, phrases and sentences when speaking to the patient.
• Speak slowly.
• Repeat or rephrase as needed.
• Ask one question at a time.
• One person should talk at a time.
• Use nonverbal communication (pointing, gestures, facial expressions, tone of voice, body language) when trying to convey messages.
• Ask simple yes-or-no questions to verify understanding.
• Use questions to confirm patient’s verbalizations. “Are you saying that you want a drink of water?”
• Include the person in conversations.
• Speak directly to the patient with aphasia and alert them to changes in topic.
• Use topics in conversation that are familiar.
• Use greetings and social talk to provide opportunities to speak. “Hello. How are you?”
• Ask questions that give choices when possible. “Do you want milk or juice?”
• Give the patient extra time to respond.
• Encourage the patient.
• Encourage multi-modality communication: gesturing, writing, drawing, use of communication board as well as talking.
• Acknowledge communication attempts, even when you do not understand.
• Do not pretend to understand the patient when you do not.

Changes in Vision and Perception

Stroke can cause different visual changes in the patient depending on the location of the stroke. After a stroke, the changes in vision are usually caused by either weakness of the eye muscles or a condition affecting the way the brain perceives information submitted through the visual system. There’s nothing wrong with the eye itself.

Some of the common visual changes are:

• Hemianopsia (visual field cut). Patient loses vision on either the left or right side.
• Double vision. Patient sees two of everything. This is occasionally corrected by patching one eye.
• Homonymous hemianopsia. Loss of half of the visual field in the same side of both eyes.
• Difficulty in depth and perception
• Neglect; decreased awareness of one side

Due to these changes in vision, patients may have difficulty with all aspects of daily life including mobility, reading, personal grooming and so on.

Changes in Sensation

Stroke patients may lose the ability to feel the difference between hot and cold, sharp and dull or the ability to feel or know what position the joints of the leg and arm are in. Patients occasionally might become hypersensitive or constantly feel “pins-and-needles” sensation. It’s common to lose sensation but still be able to move the extremity or vice versa. This is because different parts of the brain control sensation and motor movement.

• Some things family and friends can do to help are:
  Make the patient more aware of that arm or leg by either making the patient touch it and look at it.
• Remind the patient to check the arm or leg visually and repeatedly so that it doesn’t become injured because the patient will not feel it.
• Check the temperature of water for bathing.
• Wear braces as prescribed by your physical or occupational therapist.

Changes in Movement

• Paralysis—No purposeful movement in the leg or the arm
• Ataxia—Uncoordinated, non-purposeful movements
• Spasticity—Increased tone or contractions of muscles, causing stiff or awkward movements

Changes in Bowel and Bladder Functions

Problems with bladder and bowel function are common but distressing for stroke survivors. “Going to the bathroom” after suffering a stroke may be complicated by:

• Urinary incontinence—being unable to control your urination
• Urinary retention—trouble urinating or not completely emptying your bladder
• Constipation—being unable to have a regular bowel movement
• Bowel incontinence—being unable to control your release of stool

These issues occur when stroke has damaged the part of the brain that controls waste removal or the brain signals for it. In some cases, an infection or other issue maybe the problem.

Urinary Incontinence

Soon after stroke, many survivors need to use a small flexible tube, called a catheter, to urinate. When they improve, the catheter is removed and they begin a regular urination pattern again. Most stroke survivors do regain control of their bladders and urinate normally. Others continue to suffer from urinary incontinence and are unable to control their urination.

Treatments:
Treatments vary depending on the cause of your problem. Some feel the urge to urinate but cannot hold it until they reach the bathroom. Some tips that may help:

• Go to the bathroom at regular times to help train your bladder. Urinating every 2-3 hours— whether you feel the urge or not—can help prevent accidents.
• Get help from others as soon as you feel the urge to urinate. They may be able to get you to the bathroom in time.
• Drink plenty of fluids during the day and limit them in the evening. This will reduce the number of times you have to go to the bathroom at night.
• Limit caffeine and alcohol at night.
• Ask your physical therapist to help you strengthen the muscles around your bladder. Pelvic floor muscle exercises, called Kegel exercises, may help.

Urinary Retention

Also common among stroke survivors is urinary retention. This is when you do not completely empty your bladder. If untreated, it can lead to bladder stones, reflux (reverse flow of urine back to the kidneys) or a urinary tract infection (UTI). A UTI needs immediate treatment, so see your doctor as soon as you notice symptoms.

UTI symptoms include:

• Urine with a bad smell, cloudiness , blood or sediment (solid deposits)
• Burning when urinating or around a catheter
• Fever and chills
• Cramps in lower abdomen or side
• Pain in lower back
• Frequent urination or feeling like you have to go to the bathroom even though your bladder is empty

Treatments:
Special treatments may be needed for conditions that cause urine retention. In these cases, your doctor may prescribe a drug such as Ditropan®, Levsin® or Cystospaz®. Inform your doctor of other drugs you are taking, because they may be the cause of your urinary-retention.

You may still have problems, despite all attempts to correct. Use a catheter if needed. Ask your doctor which type is best for you. Try panty liners, waterproof underpants or disposable adult diapers. Be sure to carefully clean and lubricate the urinary area to avoid skin irritations. Also, drink plenty of water to dilute your urine.

Constipation and Bowel Incontinence

Constipation and bowel incontinence is involuntary release of stool and may result from:

• Reduced fluid intake
• Diet
• Not moving around enough
• Side effects from prescription drugs
• Being unaware that you need to use the bathroom
• Weakness in the muscle that holds a bowel movement until you reach a bathroom
• Being unable or reluctant to ask for help

To prevent problems, plan ahead and take extra efforts to retrain the bowel.

• Schedule a predictable pattern. It is important to restore a regular schedule of bowel movements at established times as soon as possible. Opportunities to use the bathroom should be planned according to previous bowel habits.
• Give yourself privacy.
• The sitting position allows you to lean forward, aiding the process.
• Be active during the day to stimulate the process of bowel movement.
• Eat healthy foods to reduce constipation and improve bowel control.

Treatments:
If problems persist, your doctor may suggest one of these drugs or treatments:

• A stool softener or bulk agent, called a suppository. Shaped like a bullet, suppositories are inserted into the anus 30 minutes after a meal to stimulate a bowel movement. At first, you may need a strong suppository. As your pattern changes, you can switch to a more mild form (such as glycerin).When using suppositories, you should drink more liquids than usual. Never use them for a long period of time.
• Enema or shot of liquid put into the rectum through the anus. Do the enema at a set time every day (usually morning or evening) and adhere to your schedule. If enemas cause bleeding or abdominal pain, consult your doctor right away.
• Oral Laxatives may be helpful in some cases, but be aware that their action times can be unpredictable and they can cause incontinence in a person with poor bowel control.