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Interviewer: For patients that have survived a stroke, there could be some worry that they might be at risk for a second stroke.

Dr. Steven Edgley is the Director of Stroke Rehabilitation at University of Utah Health. Dr. Edgley, what can people who have suffered a stroke do to minimize their chances of having another one?

Dr. Edgley: The most robust way to prevent another stroke or heart disease is to control hypertension. If we put these three things into three buckets, controlling hypertension, its own bucket. It's so important. The second bucket is controlling things like cholesterol or diabetes or if you have AFib, which is an abnormal heart rhythm. So these are other medical factors that lead to an increased risk of stroke and heart disease. And so I mentioned three, the three major factors, but everyone should go to their own and primary care physician to outline and identify their personal risk factors.

The third bucket is lifestyle factors. And we can break those into diet, exercise, and what I would call avoidance of smoking, drugs, controlling your alcohol intake, things like that. So lifestyle factors, away from the doctor's office, things that you would do at home.

Interviewer: How do you best control hypertension? Let's go back to that first bucket. Is that diet and exercise? Is that usually some sort of medication?

Dr. Edgley: Both. Usually, medication works best. But diet and exercise play a role in controlling high blood pressure.

Interviewer: Generally, does a stroke, a person who's had their first stroke, do they have the hypertension that would more likely need medications to control as opposed to lifestyle?

Dr. Edgley: Both are truly important. So, certainly, if you have had a stroke due to hypertension, you need to be on some medication for that.

Interviewer: And then the second bucket, cholesterol, diabetes, AFib, or other medical factors you'd be discussing with your primary care physician. Again, is that medication generally to help control those things, or we do know that diet and exercise, again, can control those factors as well?

Dr. Edgley: Yes. So I'm talking about going to your primary care physician and getting on the appropriate medications. And I think of that third bucket, so it does influence a lot of risk factors. But I think of it as its own bucket, diet, exercise, and avoidance of harmful behaviors and substances.

Interviewer: So when we get to that third bucket with lifestyle behaviors, is it more difficult for somebody who's had a stroke to manage and control their diet and exercise? Is that a little bit more of a challenge?

Dr. Edgley: It is. They may have physical impairments that make exercise really difficult. And they may have physical mobility issues that make activity more difficult and leading to the problem of obesity. And so every one of us is on either an upward spiral or a downward spiral. And it's very, very important to, if you are on a downward spiral, to break that cycle. And a downward spiral means, you know, inactivity, leads to overweight, leads to poor muscle strength, leads to more inactivity and down and down we go. And patients can break that cycle, but it's got to be a conscious choice and an active choice.

Interviewer: So in a lot of ways, what you do, which is help stroke survivors with physical rehabilitation, is really important in breaking that downward spiral. I mean, I can speak from my experience, as somebody who has not had a stroke, I know it all comes out of exercise for me. If I'm exercising, then I tend to eat better. I tend to sleep better. I tend to do all those things. And I don't know if that's the case for everybody, but I would imagine that that physical activity component is pretty important.

Dr. Edgley: Yes. And that's true. And what we really try to do, we can't be everywhere for everyone, but we can set them out on a positive course. And so the most important thing is to be on the right uphill track and not a downward track.

Interviewer: Harnessing the power of physical therapy for stroke recovery, Dr. Steven Edgley is the stroke rehabilitation medical director at University of Utah Health.

Dr. Edgley, just first off, what is the importance of physical therapy for stroke recovery?

Dr. Edgley: The reason why physical therapy is so important, and walking specifically, is that physical therapy will facilitate better walking. Better walking will facilitate better function in the home and the community, and better function will facilitate a better quality of life. And that's what we're really after. It's very important to the individual patient to regain walking and moving around capabilities.

Interviewer: Dr. Edgley, in the past few years, from what I understand, the technology or the ways that you help people recovering from a stroke start to walk again has actually changed quite a bit and improved. Tell me more about that.

Dr. Edgley: Over 15 years ago, so many stroke patients did not get the therapy they needed because it was too labor-intensive. Now we are able to use advanced techniques like bodyweight-supported harnesses.

Interviewer: Tell me what that harness does.

Dr. Edgley: Early on in the recovery process, we used to use three and four therapists. Now we can use one, maybe two therapists with the bodyweight-supported training.

We actually have in the new Neilsen Rehab Hospital have the longest what's called the ZeroG track in the world. Also possible is unweighting the body through using a pool therapy, and we now have a treadmill on the bottom of a pool that partially unweights the body. And that is actually going along with the same concept of partially unweighting of the body for increased reps and practice.

Interviewer: What I'm hearing is walking is just that important. That should be your goal, just to get out and do it. It might not necessarily be pretty at first. You've just got to go through the motions. And if you go through the motions, it will get better and your recovery will get better. Is that a fair assessment?

Dr. Edgley: To be able to effectively walk, you typically need to compile a lot of repetitions. And typically, starting from square zero, a lot of people don't really get out of bed and stay in bed for months to years. And so we find it's critically important to ambulate early and often use these advanced techniques to help in the process.

Interviewer: Dr. Edgley, if an individual recovering from a stroke doesn't have access to a ZeroG track or the treadmill that's underwater like you talked about to help them get in those reps necessary for regaining their ability to walk, what would you recommend for that individual?

Dr. Edgley: Everyone should have access to a physical therapy gym or location. Encourage your therapists to actually walk with you. And it may be that you have to have four hands on deck to fully walk safely at first, but that is what it sometimes takes.

Interviewer: I feel like if there is just one thing that somebody should take away from this is just if you've had a stroke, you've just got to start walking and figure out how to make that happen. And if you have access to great technology like the ZeroG track at University of Utah Health . . . and by all means, if you can take advantage of that, great. If not, have those people help you walk on the treadmill that has the sidebars. You've just got to get those legs moving to get that brain muscle reconnection going again and those repetitions. That's what really matters.

Do you have a story that illustrates just how important walking is, getting those repetitions in is, to stroke recovery?

Dr. Edgley: I'm thinking of one young stroke patient who was despondent and discouraged, so discouraged that she really did not walk and put forward the effort that is necessary for recovery. And that went on for months. Couple of years actually.

And when she started to be more receptive to these therapy techniques, her whole life changed as she began to be more able to walk, more able to get outdoors, and more socially active. And now she is married and chasing a toddler around. So it can have very, very wide-ranging impacts.

Amy: This is Amy Steinbreck talking with Dr. Steven Edgely, the director of stroke rehabilitation at the University of Utah Health. What do you think is helpful to promote a helpful recovery with a stroke victim?

Dr. Edgley: A lot of recovery happens, initially, without the patient doing that much. We try to facilitate optimal recovery in the first couple of months. Those brain circuits come back to function.

Amy: So, the first couple of months are the most important, in a stroke victim's recovery, would you say Dr. Edgely?

Dr. Edgley: I would not say that.

Amy: Okay.

Dr. Edgley: Because stroke recovery can happen even years down the road. But the rate of improvement typically is fastest at the early months.

Amy: Okay.

Dr. Edgley: That's due to a number of factors, specific to what's going on in the brain and [retraining] the brain cells to function. After about three to six months, it becomes somewhat more difficult to see those marked improvements, but the potential for recovery is still present. It takes the patient to challenge him/herself to do things in a way that's comfortable for them, in a way that's still challenging to them. Simple tasks around the home, using their hands or arms for simple tasks. In time, the brain will change slowly to accommodate for those new tasks and ease of movement.

Amy: It's all part of the brain, reworking those connections and reforming those connections, I assume?

Dr. Edgley: Yes, that's exactly right, and, with time, the brain will be able to lay down new connections, new circuits, and be able to find an effective work around. The main point is the patient has to keep challenging themselves, to do more and go slightly beyond their comfort zone to facilitate those changes in the brain.

Amy: Do a lot of patients find that frustrating? I know, Dr. Edgley, that I sure found that frustrating.

Dr. Edgley: It's frustrating at times, but I like to promote people training for a triathlon. Not necessarily frustrated, just challenged. Training need not be frustrating. Frustrating things are mostly a product of their own emotions. The patients are less frustrated when they see progress towards goals that are meaningful to them.

Amy: I remember in the hospital when I was just learning to walk and they had me in the wheelchair, with the railing, you know, the guided walking path.

Dr. Edgley: Yep.

Amy: I found that very frustrating. But eventually, I was able to walk with a cane, then a gait belt, and now look at me, you know?

Dr. Edgley: Yeah.

Amy: Twenty-four months later.

Dr. Edgley: Yes.

Amy: Yeah.

Dr. Edgley: Yeah so, your situation was not unique.

Amy: So, Dr. Edgley, what factors do you think in the young stroke patient, are optimal influencers on promoting a strong prognosis for a recovery?

Dr. Edgley: Setting long term goals, and those goals should be something that the patient has to reach a great deal for, like 6 to 12 months, or beyond. Then teaming up with a group of people that can help you on the process.

Amy: I would say from a personal experience, a strong support network of family and friends to push you to your limit is important.

Dr. Edgley: Yes, so, pushing people to their limits is good to a point. Sometimes people, all people just need a break in knowing what your limits are, is also important. One of the unique things about changes in the brain, in improvements is, for example, if you played the piano and worked for hundreds of hours to perfect a piece, you don't sense necessarily the brain changing to make it easier to perform the task of being able to play that piece perfectly. You may perceive the completion of that perfect piece, but the brain does not have this building, built in system to signal when you're improving. So, you actually have to look at milestones, recognize the milestones, because it's not natural to do so and give yourself credit.

Amy: The self recognition, and giving yourself a pat on the back.

Dr. Edgley: Yes.

Amy: Is often important.

Dr. Edgley: Yep.

Amy: And recognizing that the milestones and the path people will take are all different. There is different milestones and different paths.

Dr. Edgley: Absolutely. Absolutely.

updated: November 3, 2021
originally published: May 6, 2015

Amy: This is Amy Steinbrech talking with Dr. Steven Edgley, the director of stroke rehabilitation at the University of Utah Health Care.

Dr. Edgley, thank you for joining me so much in studio for a podcast on stroke recovery.

Dr. Edgley: My pleasure.

Amy: Every year, more than 795,000 people in the United States suffer a stroke. Strokes are becoming more common among young adults in the prime of their life. I'm wondering if you could tell me a little bit about stroke recovery process in the young stroke survivor.

Dr. Edgley: It's true that about 10% of stroke patients are under the age of 50. This population represents a special population in terms of the unique challenges they face that are generally in the crux of their career and raising families, and this life event is very hard for most people. I find that all stroke patients who have a loss of function, they go through certain stages of mourning or loss.
We talk about the Kubler-Ross stages of mourning, which entails denial, bargaining, things like anger, and, ultimately, acceptance. I find that especially in the young stroke patient, meaning younger than, say, 50, these patients need to be guided towards things that will improve their chances for recovery before they reach the level of acceptance. Oftentimes stroke patients don't fully realize their own potential.

Amy: So this is somewhat pushing the stroke patient to their potential and making them realize their potential?

Dr. Edgley: Exactly. It takes a lot of guidance and someone actually, a whole team of people to guide them through the barriers that they encounter, medical, physical, emotional, everything.

Amy: Right. So I guess one way to look at a stroke is it's a process from beginning to end. Stroke recovery is truly a process.

Dr. Edgley: That's exactly right. A process that takes a lot of support. For many people that are young, they have the potential to get back to high level things like driving, or returning to work. They just need a little guidance and the resources and a team of people to help them along.

Amy: Young adults are often faced with this different set of circumstances than elderly stroke patients. They have a long life expectancy in front of them.

Dr. Edgley: I think it's critical to set the patient on the right course for their next future decades. And getting them set up with the things that will truly provide quality of life, like being able to access the community, like being able to recreate and like being able to form meaningful relationships with friends and family. And for some people, like being able to return to their former employment, or at least do some service, activities, which is helpful to their overall quality of life.

Amy: Remaining engaged with community and family I'm sure is a big part of that.

Dr. Edgley: Yes. Yes.

Amy: How do young patients sell themselves short oftentimes?

Dr. Edgley: You know, when patients have a stroke, it's a really traumatic life event. They probably don't see their friends and family going through and succeeding without the process of recovery. They don't know what to expect. They don't know how to get themselves out of this black pit. I think many patients come to a certain level of comfort and realize that things will be okay in their life in terms of their basic needs, but don't really have an idea what to reach for. Many times the limits of people are limits that they put on themselves.

Amy: Self imposed. Yeah.

Dr. Edgley: Now, that's not to say that every stroke patient has the potential to get that back to 100%, the way their life was in the past. Certainly reaching and striving to get as much quality of life, and be as independent in the community is really important.

Amy: Recognizing your potential.

Dr. Edgley: Yes.

Amy: Have you experienced other people putting limits on stroke patients?

Dr. Edgley: I do see occasionally some people around the stroke patient who, based on misinformation, have some assumptions what the stroke patient's potential is. We commonly deal with this in therapy. For example, the patient's family member tries to do everything for the patient without giving them the chance to learn how to do the activities themselves. That's a common occurrence, and a simple matter of just educating the family members to let's try to promote as much independence as possible. And the way to do that is you learn by doing.

Amy: Right. Most often finding that balance, that perfect balance between independence and dependence.

Dr. Edgley: Yes.

Amy: What are some of the barriers, Dr. Edgley, do young stroke patients face in recognizing their potential?

Dr. Edgley: I would say, again, a stroke is a major life event and it requires a major life adjustment. Some people are able to adjust better than others on their own.

Amy: Right.

Dr. Edgley: Most people are able to adjust more effectively with a broad network of support, including family, friends, and rehab specialists. With time we like to promote higher level goals, like return to work if possible. For that to occur, you have generally got to have a supportive employer who is willing to take a chance. Stroke patients have the potential to be superb employees.

Amy: Dr. Edgley, what advice or tips do you have for the young stroke patient?

Dr. Edgley: Accept yourself and where you are. But don't accept the limitations that you perceive or that other people put on you.

updated: April 7, 2021
originally published: December 10, 2014

Dr. Miller: How to get your strut back after a stroke. That's next on Scope Radio.

Hi, I'm here today with Dr. Stephen Edgley. He is an associate professor in the department of physical medicine and rehabilitation in the University of Utah. Steve, a patient has had a stroke and is having difficulty walking. What do they need to do, to be able to get back on their feet again and get around?

Dr. Edgley: This is an extremely critical point that so many patients, months in, actually years in, after struggling with a stroke. The typical stroke patients are by and large...

Dr. Miller: Now, we are talking about a stroke patient where one side of the body, one leg is affected. Am I right about thinking that?

Dr. Edgley: Usually.

Dr. Miller: Usually, Okay. It's not usually both, it's in one side.

Dr. Edgley: So usually one side is weak. I'm going to stress how the importance of being as active as possible and this carries huge health consequences. We know that the insistence of heart disease, diabetes, major risk factors can actually lead to death is much greater when you're inactive.

Dr. Miller: Getting back on your feet is important for more than one reason.

Dr. Edgley: Yes, also the quality of life reasons being able to [inaudible 00:01:46] the community is also an important factor. We have a lot of research that clearly shows that if a stroke patient is able to achieve a good speed, walking speed of just 1.8 miles per hour, they will most likely an predictably be able to ask us the community, walking in the community rather than just walking and hobbling around the home.

Dr. Miller: So the need to do the physical therapy is one thing but these patients also have not just weakness sometimes but pain, spasticity of the affected side. Is that right Steve?

Dr. Edgley: Yes, That's another critical point. These patients typically need an intervention by a specialist in rehab to overcome the barriers to achieve better walking speed. Those barriers are typically things like spasticity of muscle tying their leg up, inhibiting fast walking. Things like pain and low endurance.

Dr. Miller: How often would pain occur in someone with a stroke?

Dr. Edgley: Well it depends, pain syndromes are typically exacerbated by the hemiparetic gait. So the gait mechanics being a little all off counter leads patients be more susceptible to common things like joint arthritis. There are some specific pain syndromes that occur as a result of stroke sometimes.

Dr. Miller: I would guess that the post-stroke patient who has suffered weakness to the leg is not getting this team approach that the physiatrist supplies, that their recovery is going to be delayed or really impaired.

Dr. Edgley: I see patients that have gone on for years being restricted to the home environment with little intervention and attention to these barriers can often achieve great results even to the extent of a much greater quality of life.

Dr. Miller: So what are the barriers to maybe walking faster than the 1.8 miles an hour. Can they eventually build up to a pace that is faster than that?

Dr. Edgley: Well, it depends on a lot of variables. We approach it like this, first try to break down as many barriers to walking speed as possible. And then get them into an aggressive physical therapy program. And then reevaluate the situation.

Typically if the patient can walk a limited distance at home, we can influence the situation to enable the patient to be somewhat effective at walking in the community by breaking down these barriers in a more specialized and team-oriented therapy approach.

Dr. Miller: So a patient with this stroke problem where they can't walk, once they get into therapy are we actually teaching another part of the brain to help take over?

Dr. Edgley: Often we are, the brain has significant potential to do, adapt, and change, even years after a stroke. What we are really doing in therapy, especially months and years after, a stroke is trying to capitalize on the brain's ability to be plastic and adapt. Teaching them the [inaudible 00:06:23] strategies for faster walking and more functional movement.

Dr. Miller: So, it's not just the walking? What you pointed out, is that patients after a stroke, who walk, are able to get going. As opposed to those who don't, do better in the long run, live better, and live healthier. It seems like such a simple thing, yet it has remarkable consequences.

Dr. Edgley: Indeed, it is an extremely critical and some people we now consider walking speed to be the fifth vital sign. It's something we measure in our clinic as an objective measure of how they're doing overall and how they're doing physically.

updated: July 15, 2020
originally published: August 5, 2014