Stroke

Strokes, or "Cerebro-Vascular Accidents" (CVAs) can be life-changing events, but there is increasing evidence of the benefits of appropriate exercise both in the prevention of, and recovery from strokes.Image result for images of stroke rehabilitation

When a stroke occurs part of the brain is deprived of blood and become damaged or die.  If sufficiently severe then death occurs.  The main "early days" symptoms are confusion, impaired speech and partial or total paralysis down one side.  Bladder and bowel control may also be affected.  

Improvement of each of these symptoms is highly variable but once sensation and movement start to return exercise to restore lost muscle strength and retrain balance and co-ordination is an essential part of maximising recovery.






Research:
Tai Chi Exercise and Stroke Rehabilitation
Ruth E. Taylor-Piliae and William L. Haskell Top Stroke Rehabil 2007;14(4):9–22 © 2007 

Tai Chi (TC) is an ancient form of exercise,meditation, and self-defense, widely practiced in
China for thousands of years. TC is a low-impact moderate-intensity exercise, can safely be performed by persons with a chronic disease or disability, and is popular among adults of all ages. TC is viewed as a way of life to maintain or restore health and is a powerful centering activity in which an individual learns control over some bodily functions and quiets the mind. Little reported research has specifically examined the effectiveness of TC among stroke survivors. However, TC is associated with reductions in several risk factors for subsequent stroke or disability, including better balance, lower blood pressure, and
improved mood.

The most common application of the yin-yang principle (of Tai Chi) is balance. TC movements are performed without strain, while utilizing the principle of opposites
to maintain and promote harmony and balance in the body. Individuals are instructed
to feel the ground with their feet, sink their weight to the ground, and maintain good
body alignment to promote stability and balance. Movements flow from one to another, with body weight shifting from the right leg to left leg to balance the empty and full feeling.

The second principle is relaxation. Relaxation involves both the mind and body during TC. Active relaxation involves integrating mindfulness with physical relaxation and simultaneous awareness of all parts of the body. Each movement is slow and even, promoting the flow of qi throughout the body. The mind is alert, though calm and centered while performing TC.
Centering allows an individual to access the inner self, promoting relaxation and inner peace. The goal is a calmer, clearer, nonreactive state of mind and provides the person with an internal sense of control over stress.

The third principle is coordination. The body is upright, the head is erect, the spine is comfortably aligned, shoulders are balanced and relaxed, and body weight is evenly distributed on the soles of the feet. While moving, the body remains in an upright
position with the shoulders aligned over the hips. TC movements originate in the waist to turn the whole body in unison. The waist is the center or axis and directs the movement of the arms, legs, and eyes.The head, trunk, and pelvis rotate as a single unit, aligned over a stable base in the feet. There is no twisting of the spine. Among older adults, TC can initially be taught by repeatedly practicing a series of simpler movements, slowly building coordination. Once these movements are mastered, new movements with increasing difficulty and complexity and demanding greater coordination can be gradually introduced.

Review of Literature
Typical disabilities following stroke include poor neuromuscular control, hemodynamic imbalance, and negative mood state. TC is associated with better balance, lower blood pressure, and improved mood, which are important for stroke survivors. A review of relevant TC research literature follows, examining research designs, study populations, measurement of variables, and style and duration of TC. Finally, the potential application of TC to stroke rehabilitation is discussed.

Tai Chi and balance
During the practice of TC, balance is a vital principle that is rigorously followed. Over the
past decade, the number of studies examining the effectiveness of TC exercise for improving balance has greatly increased. The majority of studies have reported that TC significantly improves balance, despite different research designs, diverse study populations, a wide variety of balance measures, different styles of TC, and varied duration of TC practice/experience. The majority of studies have been conducted among healthy older adults, though study populations have included adults with osteoarthritis, balance disorders, multiple sclerosis, stroke, or cardiovascular disease risk factors.

Significant improvements in balance have been reported, regardless of the type of balance
measure used.

Despite study limitations, including few rigorously conducted studies, varied balance measures, and different styles and duration of TC exercise, TC significantly improved balance and was a safe and feasible exercise option for persons with chronic health conditions, including stroke survivors.

Tai Chi and blood pressure
High blood pressure (BP) following a stroke places stroke survivors at greater risk for a subsequent stoke.However, relatively few studies have examined the effect of TC on BP,
and no reported studies have specifically examined the effect of TC on BP among stroke survivors. Participants were mainly healthy middle-aged or older adults, though study populations included adults with cardiovascular disease risk factors, such as hypertension, or postmyocardial infarction.


Tai Chi and mood
Depression or negative mood are common feelings experienced by stroke survivors, further compounding recovery. The mental concentration or mindfulness associated with TC is thought to promote peacefulness or tranquility, reducing stress and tension, while improving overall mood.

All studies reported significant improvements in overall negative mood, while four
studies reported significant reductions in depression. Duration of the TC interventions ranged
from 8 to 16 weeks, making comparisons difficult. Rigorous studies using a randomized clinical trial design with sufficient sample size are needed to definitely determine if TC effectively improves mood or reduces depression.

Tai Chi and stroke survivors
To date, only one published study has examined the effect of TC among stroke survivors. A total of 18 subjects participated and were able to independently perform their activities of daily living and walk with assistance. All participants attended group-based exercise
classes twice a week for 12 weeks, randomly assigned to either TC or balance training (controls). Controls had a significantly greater increase in balance than TC, following the intervention. However, it is likely that both the TC and controls had similar balance training exercise conditions. Other possible explanations for the findings reported include the small sample and limited amount of TC instruction and practice that participants received. Additional research with a sufficient sample and rigorous study design for examining
TC as an alternative exercise in stroke rehabilitation is needed before firm conclusions
can be made. However, the study reported the safety and efficacy of TC as an exercise modality among stroke survivors; the study also noted that participants enjoyed TC.

Application of Tai Chi to Stroke Rehabilitation
Balance is an essential component of successful movements associated with activities of daily living (e.g., walking, reaching, bending) as well as fall prevention, which is important for stroke survivors. TC likely facilitates improvements in balance through
the development of proprioceptive awareness and kinesthetic sense.Proprioceptive awareness and kinesthetic sense are reported to diminish with age or following a stroke. Kinesthetic sense or the perception of movement is mediated by the body’s proprioceptive
mechanisms enabling it to receive stimuli from receptors originating in the muscles, tendons, and joints, through which these movements can be adjusted accurately for maintaining balance. Proprioceptive awareness and kinesthetic sense are important for coordinated movements, body posture, and motor learning (relearning), which are essential
to stroke survivors for adequate neuromuscular functioning.

Constant weight shifting, trunk rotation, a changing base of support, and an elongated central axis around which all movements occur are fundamental to TC exercise. The slow, rhythmic movements of TC are linked together in a continuous sequence, while body weight is continually shifting from leg to leg without compromising balance or stability. Shifting body weight during TC to different positions (e.g., forward, backward, side-to-side) in a smooth and coordinated manner challenges the balance control system to maintain the center of mass within the base of support. Repetitive demands of this balance control system occurs during the practice of TC and may help explain how TC facilitates better balance.30 Several TC movements are directly related to elements of balance. 

Impaired proprioception in older adults makes it difficult for them to detect changes in their body position until it is too late for compensatory movements to prevent falls. In older adults with hemiparesis following a stroke, proprioception and kinesthetic sense is likely impaired further. During TC, each movement is scrutinized for correct body position and foot placement, important for performing TC safely without injury, while subjects learn or relearn proprioceptive awareness and kinesthetic sense. Continual practice of TC among older adults develops and strengthens proprioceptive awareness and kinesthetic sense and may
also aid balance control in stroke survivors. In addition, during performance of TC the knees
are bent, which strengthens the quadriceps, knee extensor, and flexor muscle strength. Primary knee flexors are the hamstrings and gastrocnemius muscles, which are two-jointed muscles. The hamstrings cross the hip and knee joints, while the gastrocnemius cross the knee and ankle joints. During TC, bending the knee requires hip flexion and simultaneous dorsiflexion. Previous research among older adults has reported significant increases
in lower body strength and flexibility following a TC intervention. TC likely facilitates
improvements in both lower body strength and flexibility, further aiding in balance control.
TC exercise is often prescribed by Chinese doctors as a treatment for hypertension. The softness and low-impact nature of the movements without force or pressure are ideal for persons with hypertension. The muscle relaxation created by TC is thought to foster a conditioned relaxation reflex in the blood vessels, resulting in lower blood pressure.
 This BP response is important for older adults, as they often experience age-associated declines in physiological functioning, and for stroke survivors. In addition, the relaxation response that occurs is further enhanced through the mindfulness and active relaxation during TC.Mindfulness and active relaxation during TC focuses on body position (e.g., correct foot placement) and how the body feels (e.g., shoulders relaxed). It involves being alert and calm at the same time, while leading to improvements in mood or mental outlook, an important aspect of care and rehabilitation among stroke survivors.

Conclusion
Stroke is the leading cause of serious, long-term disability among middle-aged and older adults in the United States. Typical disabilities following stroke include poor neuromuscular control, hemodynamic imbalance, and negative mood state. Reported research to date, indicates that TC exercise is associated with better balance, lower blood pressure, and improved mood, which are important for stroke survivors. TC is safe for older adults with chronic diseases or disabilities and may serve as an additional exercise modality for rehabilitation among stroke survivors. However, additional research with a sufficient sample and rigorous study design among stroke survivors is needed before widespread recommendations can be made for TC as an alternative exercise in stroke rehabilitation.
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Image result for images of stroke rehabilitation

right: Restoring hand movement and control.