Modern Psychological Studies

Volume 3 Number 2 Article 4

1995

Recovery from stroke involving the left middle cerebral artery

Lori Walter Colorado College

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Recommended Citation Walter, Lori (1995) "Recovery from stroke involving the left middle cerebral artery," Modern Psychological Studies: Vol. 3 : No. 2 , Article 4. Available at: https://scholar.utc.edu/mps/vol3/iss2/4

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Recovery From Stroke Involving neglect of the right visual field, and global aphasia (difficulty in all communication the Left Middle Cerebral Artery processes). When the lesion occurs in the Lori Walter anterior branches of the MCA, there is increased risk of executive control deficits Colorado College (Beeson, Bayles, Rubens, & Kaszniak, 1993; Huff, Mack, Mahlmann, & Abstract Greenberg, 1988) and long-term memory The rehabilitative treatment of a 73-year- impairment (Beeson et al., 1993). old male who suffered from a left middle The prognosis for recovery from cerebral artery (MCA) thrombotic infarct left hemisphere MCA is fairly positive. In was observed to analyze the effects of age Kaste and Waltimo (1976), 72% of the and psychological and social factors on MCA patients who survived the acute stroke recovery. The patient was assessed phase of stroke became fully independent, as having minimal verbalization, right 27% required assistance, and only 1% side neglect, right hemiparesis, right were completely disabled. Several factors hemisensory deficits, decreased balance such as age, medical environment, and and mild dysphasia. After 29 days of social interactions may affect stroke physical therapy, occupational therapy, recovery. and speech therapy, he showed Recovery from stroke may be improvement in activities of daily living, dependent upon the patient's age. Some walking, and communication. He was researchers (Ahlsio, Britton, Murray, & discharged 33 days poststroke (DPS). Age Theorell, 1984; Kaste & Waltimo, 1976; of the patient and severity of the stroke Kotila, Waltimo, Neimi, Laaksonen, & seemed to be poor predictors of stroke Lempinen, 1984; Wade, Wood, & Hewer, outcome. Early rehabilitation, patient 1985) have shown that older patients have motivation, family support, and treatment less positive effects from rehabilitation in a rehabilitation unit appear to have than younger patients with similar severity positively influenced his recovery and may of stroke. Other research found age to be be good predictors of rehabilitative unrelated to stroke recovery (Bonita & success. Beaglehole, 1988; Feigenson, McCarthy, Greenberg, & Feigenson, 1977a; In order to illustrate the effects of Heinemann, Roth, Cichowski, & Betts, age and psychological and social 1987). The present study questions interactions on stroke recovery, the whether age can predict rehabilitative present study documents a stroke patient's success. rehabilitative progress from hospital Social and psychological factors admittance to discharge. The patient, CH, may be more indicative of stroke a 73-year-old Caucasian male was outcome than chronological age. The diagnosed as having an evolving left patient's self-motivation and interaction hemisphere cardiovascular accident with the rehabilitation staff, interaction (CVA), located in the middle cerebral with the family, or all three combined may artery (MCA). The left MCA supplies the be more representative of stroke recovery lateral aspect of the left cerebral (Feigenson, 1979; Feigenson et al., 1977a; hemisphere. When an infarct affects the Kaufman & Becker, 1986; Reding & MCA, cerebral processes such as McDowell, 1989; Strand et al., 1985). communication, perception, sensation, and Older patients with less positive voluntary movements can be impaired. recovery in studies by Ahlsio et al. (1984), Clinical manifestations of left-hemisphere Kaste & Waltimo (1976), Kotila et al. MCA ischemia are characteristically (1984), and Wade et al. (1985) may have dense contralateral hemiplegia (more had less social support and less motivation severe in the upper extremity than the than the younger patients, which is not lower), loss of sensation on the right side, uncommon for elderly persons (Kaufman & Becker, 1986). Therefore, an older

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Lori Walter

stroke patient with strong motivation, magnetic resonance imaging test (MRI) family support, medical support, or all indicated the CVA was located in the three combined may have a higher degree putamen and parts of the caudate as well of recovery regardless of his or her age. as in the intervening gray matter (see In order to examine the effects of Figure 1). Patchy areas in the peritrigonal age and psychosocial factors on stroke recovery, CH, a 73-year-old man, was chosen for this study. He was treated in an early intervention team rehabilitation approach which has been shown to increase staff interest, communication, and expertise in a patient's recovery as well as increase patient interaction with other rehabilitation patients (Feigenson, Gitlow, & Greenberg, 1979). CH also had

4.11 NZ • good family support and motivation which •••• I • 1•16 • • has also been shown to positively affect a. see stroke recovery (Feigenson, 1979; • ••••1 • Feigenson et al., 1977a; Kaufman & Becker, 1986; Reding & McDowell, 1989; Figure 1. Magnetic Resonance Image (MRI) Strand et al., 1985). The present case depicting the coronal view of the left hemisphere. study suggests, despite his advancing age, The infarct arrows are located in the putamen, CH will have a positive outcome due to parts of the caudate, intervening gray matter, and his strong social and psychological extensions into the left cerbral peduncle and left factors. occipital horn. CH's prognosis considering the patient's age and stroke severity was rated region and extensions into the left cerebral as "fair" by the rehabilitation team at four peduncle and left occipital horn were also days poststroke (DPS). CH was affected. The result was a mass effect on subsequently transferred to a rehabilitation the left ventricular body, with sparing of the peripheral gray. Mild volume loss of wing and was treated in a the brain was present, but was not multidisciplinary stroke rehabilitation significant for the age. The final program. The present case study assessment from these tests was a documents CH's recovery from left MCA infarct by first assessing anatomical and subacute, nonhemorragic, mildly swollen functional deficits at stroke onset. infarct of the left hemisphere due to a Detailed daily notation in physical, thrombosis in the lateral striate branches occupational, and speech therapy follows of the left MCA. to identify progress in all aspects of Functional assessment rehabilitation. CH's mental status was reported on Case History the day of the stroke as alert. He was able to follow one step commands with 50% Anatomical assessment accuracy. CH demonstrated vocalization but minimal verbalization with respect to A series of tests helped locate the discrete words. He manifested expressive exact origin of the CVA. A computerized aphasia and mild right side neglect. tomography (CT) scan showed minimal Physically, CH had right hemiparesis, increase in cortical sulci, within normal right hemisensory deficits, decreased limits for age, and no midline shift, mass sitting and standing balance, and mild effect, hemorrhage, abnormal hypodensity dysphasia. The diagnosis was a severe or hyperdensity. A carotid imaging test stroke with "fair" prognosis from the with doppler presented no rehabilitation team. CH began hemodynamically significant stenosis. A rehabilitation four DPS.

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Physical Therapy functional approach, based on completion of tasks, and the neuromuscular Three aspects of therapy were facilitation approach, aimed at recovery employed to increase his level of through sensory cues. In the first few days functioning: physical therapy, of physical therapy, bed mobility and occupational therapy, and speech therapy. static sitting were emphasized. Training CH was treated with a comprehensive CH to walk (gait training) was attempted remobilization program on four DPS to on 10 DPS. Muscles were retrained for increase his bed mobility and ambulation. gait through slow, deliberate movements His physical therapy progress is detailed to enlist intact motor and sensory cyclic in Table 1. This treatment involved the systems. Ambulation is normally begun when the patient can understand three-step Table 1 commands, can maintain standing balance, lacks hip, ankle or knee CH's Physical Therapy Progress. contracture, and has normal voluntary motor function of the hip, knee, and ankle DPS Progress of Therapy (Jann, Rusin, & Kovan, 1992). Because 1 CH was not this advanced at 10 DPS- he 2 began walking with a straight cane. As is 3 common in early gait training (Jann et al., 4 5 1992), CH performed shorter steps when 6 walking, exhibited longer duration stance, 7 MNA sitting bedside and had a shorter swing phase during gait. 8 Also characteristic was his circumduction 9 of the affected limb, knee flexion, and a 10 Sitting IND, MDA gait with cane decrease in ankle mobility. Subsequently, 11 he showed toe drag and needed moderate 12 MNA wheel chair mobility assistance to weight shift to the unaffected 13 MNA standing, maintain for 10 s side and to advance the right leg. 14 MNA roll to left, IND roll to right By the third week of recovery, CH SBA supine to sit, MNA sit to stand 15 could roll to the right independently and 16 17 MNA/MDA gait with cane to the left with verbal cues. His transfers 18 SBA sit to stand, IND supine to sit from the supine position to sitting were 19 SBA/MNA gait, MNA stair climbing done with standby assistance. CH 20 IND bed mobility, SBA up stairs, CGA performed sitting to standing transfers down stairs with minimal assistance. Gait was graded 21 as poor and was emphasized with his 22 family during visitation as well physical 23 therapy sessions. At 19 DPS, CH began 24 Gait 200 ft with cane, verbal cues practicing stair climbing, a functional skill 25 MNA stationary bike mount & dismount that has a beneficial effect on gait 26 Increased speed in gait with cane (Charness, 1986). By 20 DPS, CH only 27 CGA/SBA gait 400 ft with cane, needed standby assistance ascending stairs SBA/CGA stairs 28 CGA/SBA gait 1000 ft with cane and contact-guard assistance descending 29 stairs. Four weeks poststroke, CH walked up to 1000 feet with slight facilitation of 30 31 SBA gait 900 ft without cane, SBA/CGA the physical therapist to weight shift to the stairs left. Sensory cues from the environment 32 Able to talk and walk simultaneously and from the physical therapist aided the patient in coordinating his movements Note. MDA = moderate assistance; MNA (Voss, Ionta, & Myers, 1985). CH's wife minimum assistance; SBA = standby assistance: and son were present at the next few CGA = contact guard assistance: IND = physical therapy sessions to learn transfer independent. skills and aid CH in walking in

MODERN PSYCHOLOGICAL STUDIES 23

Lori Walter

anticipation of his discharge (Eakin, it was clear that CH's right hand was not 1991b). On 31 DPS, CH no longer used able to perform fine motor skills. the straight cane and could gait 900 feet with standby assistance as well as ascend Table 2 and descend 3 flights of stairs. Upon CH's Occupational Therapy Progress. discharge at 33 DPS, CH showed significant improvements in mobility and DPS Progress of Therapy transfers and exhibited good functional 1 control of his right lower extremity 2 including isolated control across his right 3 hip and knee. 4 MDA sitting, grooming, MXA dressing LB Occupational Therapy 5 MNA dressing UB 6 - - - - Occupational therapy was 7 MNA sitting employed to improve CH's basic self-care 8 skills such as dressing, grooming, and 9 bathing. A chronology of his recovery is 10 MNA supine to sit, MDA grooming provided in Table 2. A sensorimotor 11 MXA dressing LB, MNA dressing UB technique was used to normalize tone, 12 MNA standing transfer 13 MDA dressing LB, MNA grooming promote good posture, and to facilitate 14 SBA dressing UB, MNA dressing LB, motor planning on the affected side. The began writing with left hand, shaky stroke functional approach was integrated when 15 the affected side was unable to perform 16 certain activities. For CH, this meant 17 SBA grooming, SBA transfer from bed to training the left hand in writing to wheelchair compensate for the loss of fine motor 18 CGA dressing LB, gross grasp good with skills in the right hand. R hand Therapy focused on promoting 19 Able to trace 1/4" lines with L hand intrinsic, neurological functioning in the 20 IND grooming, gross grasp R hand with early stages of stroke (Eakin, 1991a). On 2" disc 21 Increase in wrist control in L hand four DPS, CH was given sensory 22 stimulation to facilitate proper posture and 23 to help him maintain a stable sitting 24 Able to form letters with L hand in 1 balance. CH was also supervised daily in stroke hygiene and dressing. Initially, CH needed 25 Uses R arm in self-care skills moderate assistance grooming at the sink 26 R hand able to 3-point pinch in his wheelchair and for standing 27 Improved coordination, 2- and 3-point transfers. Maximum assistance was pinch necessary at times for dressing the lower 28 body, but minimal assistance was needed 29 for upper body dressing. His mobility and 30 functioning in activities of daily living 31 Supervision when dressing 32 Functional pinching improving steadily (ADL) progressed uniformly. 33 Supervision in grooming, dressing, and By 2 weeks poststroke, CH needed transfers only standby assistance in donning clothing but still did not initiate movement Note. MXA = maximum assistance; MDA = on the right upper extremity to help in moderate assistance; MNA = minimum assistance; dressing. The following week, CH began SBA = standby assistance; CGA = contact-guard using his right arm in self-care tasks; assistance; IND = independent; UB = upper body; assistance in dressing, especially the lower LB = lower body; R = right; L = left. body, decreased. At this time, CH was able to groom himself independently. Consequently, his left hand was trained in Despite integration of the right arm, writing his name on 14 DPS. CH was able

24 MODERN PSYCHOLOGICAL STUDIES

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to copy simple patterns but his strokes function with 80% accuracy. One week were short and shaky. By 24 DPS, CH later, CH could identify simple objects in began to isolate wrist and hand a field of five with 90% accuracy and movements for more precise lettering and could write his first name with his left smoother strokes. hand with only one error. His oral On 26 DPS, CH began using his movements were rated as fair in verbal right hand in a three-point pinch pattern to place large pegs in a peg board. At 27 Table 3 DPS, CH exhibited improved coordination and continued right arm movement CH's Speech Therapy Progress. patterns, grasp and release techniques, and pinching in two and three-point DPS Progress of Therapy techniques. His functional pinching 1 improved steadily. After 33 days, CH 2 could groom, transfer, and dress himself 3 independently with supervision for safety. 4 5 Identify in field of 2, 90%; field of 3, CH was able to write his name with his 50% left hand with no errors. To assure safety 6 Yes/No questions, 80% of the patient and prevent excessive care 7 Identify in field of 2, 100%; field of 3, of the patient at home, the family 40%; unable to follow 1 step commands members were trained in standby 8 - - - assistance and patient supervision. A week 9 - - - before discharge, CH's wife and son aided 10 1 step commands, 65%; write first name, in therapy sessions in preparation of CH's 80% discharge. 11 Identify in field of 4, 70%; Yes/No questions, 80% Speech Therapy 12 1 step commands, 80% 13 Identify pictures by name, 70%; by The goal of speech therapy is to function, 80% 14 Yes/No questions, 75%; count 1-10, improve all communication skills by 100% assessing the communication strengths of 15 - - - - the patient and utilizing these strengths to 16 retrain the lost skills (Albert & Helm- 17 Name objects in a field of 5, 90%; count Estabrooks, 1988). CH's therapy progress 1-20, 90%; 2-step commands, 50% is detailed in Table 3. Because he had 18 Say days of week, 60%; oral movements better reading than auditory fair comprehension at four DPS, CH's first 19 Able to write first name, 1 error task was to identify functional objects on 20 Point to written words, 80% a card. He could correctly identify objects 21 Able to spell 3-4 short, 3-4 letter words in a field of two with 90% accuracy but 22 23 dropped to 50% accuracy in a field of 24 Imitation monosyllable words, 50% three. His slight right side neglect also 25 Point to word in communication book, affected his performance. He was unable 70% at this time to follow oral motor 26 Write last name with left hand, 2 errors commands, but he could answer yes-no 27 Vowel imitation, fair questions at 80% accuracy. By 10 DPS, 28 Name 2-3 items in categories; read 2-3 CH could respond correctly to one-step words, 70%; vowel imitation, 60% 29 commands 65% of the time and could copy his first name correctly with his left 30 - - - - hand with 80% accuracy. 31 Imitation of 2-3 word phrases, 65%; 2- After 2 weeks of recovery, CH step commands, 60% 32 responded to one-step commands with Trouble reading function-similar words 80% accuracy and could identify pictures imitation of the vowels "ah," "oo," "ee". In by name with 70% accuracy and by

MODERN PSYCHOLOGICAL STUDIES 25 Lori Walter all, CH exhibited excellent progress and a Early intervention of rehabilitation communication book was created to work has been shown to positively influence on pronunciation of family members' outcome from stroke (Strand et al., 1985). names, his address, and other words used Dombovy, Bosford, Whisnant, and daily. Berystralh (1987) found early stroke By the fourth week of recovery, rehabilitation with a mean delay of five CH could point to -the appropriate word in days was beneficial to final outcome of the communication book with 70% stroke patients. CH's favorable recovery accuracy and could write his last name began four DPS, contributing to the with his left hand with only two errors and benefits of early rehabilitation. Dombovy his first name with no errors. CH's vowel et al. (1987) also found that patients imitations were still fair 27 DPS, when he treated with team therapy exhibited began working on categorical naming. substantially greater recovery than CH's family constantly encouraged him to patients treated with either physical speak to them and use his communication therapy or occupational therapy alone. book to express things. At the end of the Focused stroke rehabilitation programs, fourth week, CH could name two to three similar to CH's therapy, result in higher items in basic categories and vowel functioning in activities of daily living and imitation was at 60%. mobility conditions (Reding & McDowell, One day before discharge, CH was 1989). The 29 days CH spent in assessed on reading and identification multidisciplinary therapy appears to have tasks. CH had the most trouble with words positively affected CH's outcome. of similar semantic structure as opposed It has been demonstrated that to words with similar spelling or rhyming motivated patients do better in recovery words. According to Beeson et al. (1993), than less motivated patients (Feigenson et CH's deficit could be partly due to al., 1977a; Kaufman & Becker, 1986). executive control impairment. Because older patients tend to be less Unfortunately, this hypothesis could not motivated or even resigned to their illness be tested. CH was discharged 33 DPS. He (Kaufman & Becker, 1986) their could produce single and multiple words prognosis from stroke can be less positive with enough consistency to express his than younger, more motivated patients. needs. His comprehension was greatly CH was highly motivated, which may improved and he was able to follow more explain his considerable recovery despite complex verbal commands. his advanced age. Generally, elderly patients have Discussion less family and administrative support (Kaufman & Becker, 1986). In such cases, CH's ultimate recovery from a left the valuable psychosocial support (Ahlsio MCA infarct was more positive than et al., 1984) is missing and all stages of expected by the medical staff. By 33 DPS, the recovery process may be hindered he showed considerable improvements in (Feigenson, 1979; Reding & McDowell, walking, activities of daily living, and 1989; Strand et al., 1985). The communication. From a neurological enthusiastic presence of CH's family at standpoint, CH demonstrated significant therapy sessions and visitation hours improvement in all areas. Such substantial seems to have aided in his recovery. gains were not anticipated by the rehabilitation team considering the Conclusion severity of CH's infarct and his advanced age. Early rehabilitation, team therapy, The survival rate for stroke patient motivation, and family support patients has increased over the last decade may have all positively affected his (Garraway, Whisnant, & Drury, 1983), outcome. In conclusion, severity of stroke which may be due to rehabilitation and age alone may not be accurate therapy. Because the cost of hospital care predictors of rehabilitative success. and rehabilitation of stroke patients has

26 MODERN PSYCHOLOGICAL STUDIES RECOVERY FROM STROKE risen from $19,285 in 1976 (Feigenson, all therapists, followed closely by personal 1979) to $26,109 in 1994 (Universal Data mobility and System [UDS], 1994), it is increasingly social situation. CH's therapists important to analyze the benefits of the considered personal mobility, personal system. The present study demonstrated support, and general health status the most that patients with left MCA strokes can be important variables in assessing discharge. treated successfully with early CH had improved walking, ADL, and intervention in a rehabilitation unit of a communication by 33 DPS. CH was in hospital. Family support and patient good health and had sufficient family motivation also appear to positively affect support to be discharged on 12-21-94. He outcome. will continue with home and outpatient Previous research was unclear as therapy for up to three months because to whether age was a detriment to stroke little benefit from therapy occurs beyond recovery. CH's prognosis from the that time (Sivenius, Pyorala, Heinonen, medical staff, who accounted recovery Salonen, & Reikkinen, 1985). However, upon age and severity of stroke, was less CH's recovery should, according to positive than his true recovery. This study previous studies (Heinemann et al., 1987; concludes that age will not necessarily Kotila et al., 1984; Shewan & Kertesz, dictate stroke recovery. Psychosocial 1984; Wade et al., 1985), continue for the factors such as social interactions and self- next two months. motivation seemed to have influenced CH's outcome and thus may reveal a more References accurate prognosis for recovering stroke patients. Ahlsio, B., Britton, M., Murray, CH stayed almost twice as long on V., & Theorell, T. (1984). Disablement the rehabilitation unit than the national and quality of life after stroke. Stroke, 15, average of 16 days (UDS, 1994). This was 886-890. probably due to the severity of his stroke. Albert, M., & Helm-Estabrooks, Although stroke severity may dictate N. (1988). Journal of the American length of stay, it may not be a good Medical Association, 259, 1205-1209. indicator of stroke outcome (Feigenson, Beeson, P., Bayles, K., Rubens, McDowell, Meese, McCarthy, & A., & Kaszniak, A. (1993). Memory Greenberg, 1977b). CH exhibited impairment and executive control in substantially greater recovery than others individuals with stroke-induced aphasia. with the same severity of left MCA lesion, Brain and Language, 45, 253-275. demonstrating that outcome cannot always Bonita, R., & Beaglehole, R. be predicted by the severity of the infarct. (1988). Recovery of motor function after Hospital discharge may coincide stroke. Stroke, 19, 1497-1500. with a plateau in recovery (Wade et al., Charness, A. (1986). Putting it 1985), but this is not always the case. together: Specific outcomes. In F. Several factors are important in assessing Schneider (Ed.), Stroke/Head Injury (pp. discharge including: severity of the stroke, 205-305). Rockville, MD: Aspen. financial resources, the patient's Dombovy, M., Bosford, J., perception of his or her disabilities, Whisnant, J., & Berystralh, E. (1987). physical characteristics of the home, and Disability and use of rehabilitation the ability of relatives to care for the services following stroke in Rochester, patient (Kaufman & Becker, 1986). Minnesota: 1975-1979. Stroke, 18, 830- Unsworth and Thomas (1993) evaluated 836. nurses, speech therapists, occupational Eakin, P. (1991a). Occupational therapists, physical therapists, and social therapy in stroke rehabilitation: workers to see which variables were most Implications of research into therapy important in assessing discharge of a outcome. British Journal of Occupational stroke patient. The results were variable Therapy, 54, 326-328. but ADL skills seemed most important to Eakin, P. (1991b). The outcome of

MODERN PSYCHOLOGICAL STUDIES 27 Lori Walter

therapy in stroke rehabilitation: Do we Reding, M., & McDowell, F. know what we are doing? British Journal (1989). Focused stroke rehabilitation of Occupational Therapy, 54, 305-307. programs improve outcome. Archives of Feigenson, J. (1979) Stroke Neurology, 46, 700-701. rehabilitation: Effectiveness, benefits, and Shewan, C., & Kertesz, A. (1984). cost. Some practical considerations. Effects of speech and language treatment Stroke, 10, 1-3. on recovery from aphasia. Brain and Feigenson, J., Gitlow, H., & Language, 23, 272-299. Greenberg, S. (1979). The disability Sivenius, J., Pyorala, K., oriented rehabilitation unit-a major factor Heinonen, 0., Salonen, J., & Reikkinen, influencing stroke outcome. Stroke, 10, 5- P. (1985). The significance of intensity of 8. rehabilitation of stroke-a controlled trial. Feigenson, J., McCarthy, M.-L., Stroke, 16, 928-931. Greenberg, S., & Feigenson, W. (1977a). Strand, T., Asplund, K., Eriksson, Factors influencing outcome and length of S., Hagg, E., Lithner, F., & Wester, P. stay in stroke rehabilitation unit. Stroke, 8, (1985). A non-intensive stroke unit 657-663. reduces functional disability and the need Feigenson, J., McDowell, F., for long-term hospitalization. Stroke, 16, Meese, P., McCarthy, M.-L., & 29-34. Greenberg, S. (1977b). Factors Universal Data System. (1994). influencing outcome and length of stay in Unsworth, C., & Thomas, S. a stroke rehabilitation unit. Stroke, 8, 651- (1993). Information use in discharge 656. accommodation recommendations for Garraway, W., Whisnant, J., & stroke patients. Clinical Rehabilitation, 7, Drury, I. (1983). The changing pattern of 181-188. survival following stroke. Stroke, 14, 699- Voss, D., Ionta, M., & Myers, B. 702. (1985). Patterns of motion. i n Heinemann, A., Roth, E., proprioceptive neuromuscular facilitation Cichowski, K., & Betts, H. (1987). (pp. 1-209). Philadelphia: Harper & Row. Multivariate analysis of improvement and Wade, D., Wood, V., & Hewer, R. outcome following stroke rehabilitation. (1985). Recovery after stoke-the first 3 Archives of Neurology, 44, 1167-1172. months. Journal of Neurology, Huff, F., Mack, L., Mahlmann, J., Neurosurgery, and Psychiatry, 48, 7-13. & Greenberg, S. (1988). A comparison of lexical-semantic impairments in left Acknowledgements hemisphere stroke and Alzheimer's disease. Brain and Language, 34, 262- The author is indebted to the 278. rehabilitation staff at Penrose Hospital for Jann, B., Rusin, M., & Kovan, B. their wealth of knowledge and kindness (1992). Rehabilitation and the stroke for allowing me to observe their therapy patient. In G. Fletcher, J. Banja, B. Jann, sessions. I would also like to thank Joyce & S. Wolf(Eds.), Rehabilitation medicine Spilka-Stafford, manager of inpatient (pp. 9-57). Philadelphia: Lea & Febiger. services at Penrose Hospital, for allowing Kaste, M., & Waltimo, 0. (1976). me this opportunity and Renee Prognosis of patients with middle cerebral Rabinowitz, legal counsel of Colorado artery occlusion. Stroke, 7, 482-485. College, and Jeanne Wilson, risk manager Kotila, M., Waltimo, 0., Neimi, of Penrose Hospital, for helping organize M.-L., Laaksonen, R., & Lempinen, M. this project. Sincere thanks goes to Bob (1984). The profile of recovery from Jacobs for his help in setting up the stroke and factors influencing outcome. observation and for comments on earlier Stroke, 15, 1039-1044. drafts. Additional gratitude is extended to Kaufman, S., & Becker, G. (1986). Robert Madigan for his advice and Stroke: Health care on the periphery. support on the final draft. Social Science and Medicine, 22, 983-989.

28 MODERN PSYCHOLOGICAL STUDIES