On average, one American will have a stroke every 40 seconds, totaling 795,000 new or recurrent strokes annually. Stroke is the number one cause of adult disability globally. Therefore, post-stroke management is critical for those who experience and survive a stroke, and more than two-thirds of stroke survivors in the United States receive rehabilitation services after hospitalization. Because it is estimated that 90% of stroke risk is due to modifiable risk factors, post-stroke treatment also emphasizes therapeutics that mitigate these risks to prevent recurrent stroke and other cardiovascular events from occurring. Targeted complementary and integrative medicine (CIM) can help with post-stroke management. This article will discuss a sample protocol incorporating CIM modalities that can be implemented with conventional rehabilitation strategies to help stroke survivors improve motor, speech, and sensory functions. (1-4)

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What Is a Stroke?

A stroke, sometimes called a brain attack, is an emergent situation when blood flow is blocked to a part of the brain by a blood clot or ruptured blood vessel. In either case, oxygenated blood is not delivered to the part of the brain affected, and brain cells die within minutes of the event, potentially causing lasting brain damage, disability, and death. (5)

There are two types of stroke. Ischemic strokes account for 87% of all strokes and occur when blood clots or plaque deposits block the blood vessels in the brain. Hemorrhagic strokes, making up the other 13% of stroke cases, occur when a weakened artery in the brain leaks blood or ruptures, putting too much pressure on surrounding brain cells and damaging them. (5, 6)

A transient ischemic attack (TIA) is often called a "mini-stroke." It differs from the major types of stroke because blood flow to the brain is blocked for usually no more than five minutes. However, TIAs still require emergent medical care because there is no way to know whether initial symptoms are from a TIA or a major stroke. TIAs are warning signs for future strokes; more than one-third of people who have a TIA and don't get treatment will have a major stroke within one year. (5)

What Causes a Stroke?

The leading cause of ischemic strokes is atherosclerosis causing a blood clot. Other factors contributing to blood clot formation include clotting disorders, atrial fibrillation, and anatomical heart defects. (6, 7)

Two types of weakened blood vessels usually cause hemorrhagic stroke. An aneurysm is a ballooning of a weakened blood vessel, which can rupture when left untreated. An arteriovenous malformation (AVM) is a cluster of abnormally formed blood vessels prone to rupture. The most common underlying cause of hemorrhagic stroke is high blood pressure (hypertension). (6)

Many factors can generally increase the risk of major stroke. African American or Hispanic men over age 55 have the highest risk of stroke. Other stroke risk factors include high cholesterol, type 2 diabetes, tobacco or illegal drug use, excess alcohol consumption, obesity, physical inactivity, obstructive sleep apnea, preexisting cardiovascular disease or migraines, family history of stroke or heart attack, and use of estrogen-containing hormone therapy. (7, 8)

Stroke Symptoms

Use the acronym "FAST" to quickly recognize the signs of a stroke:

• Facial drooping when asked to smile
• Arm weakness and downward drifting when raising arms
• Slurring or difficulty speaking
• Time to call 911 and note the time when symptoms first appeared

Other stroke symptoms include sudden onset of (8):

• Confusion and difficulty understanding what others are saying
• Paralysis or numbness in the face, arms, and legs that often affects just one side of the body
• Blurred, blackened, or double vision in one or both eyes
• Severe headache
• Dizziness, loss of coordination, and trouble walking

A stroke can cause temporary or permanent disabilities, depending on the location of the brain obstruction and how long the brain tissue lacked blood flow. Such complications may include (8, 9):

• One-sided body paralysis on the opposite side from where the stroke occurred (i.e., if a stroke occurred in the left brain, then paralysis will occur on the right side of the body)
• Difficulty talking or swallowing
• Memory loss and difficulty thinking, reasoning, and understanding concepts
• Pain and numbness in the body parts affected by the stroke
• Loss of vision, hearing, or touch
• Loss of bladder control
• Behavioral changes and emotional lability
• Increased risk for blood clots, osteoporosis, pneumonia, seizure, and brain swelling

Functional Medicine Labs That Can Help Individualize a Post-Stroke Treatment Plan

Functional medicine labs can greatly help patients and doctors understand and quantify an individual's cardiovascular disease (CVD) risk and the contributing risk factors leading to stroke. These lab results can help customize post-stroke treatment protocols that modify these risk factors to prevent the risk of future strokes. Here are functional medicine labs to consider ordering for patients recovering from a stroke.

Advanced Lipid Panel

An NMR LipoProfile is a type of lipid panel that directly measures the amount of low-density lipoprotein (LDL) particles circulating in the body, which are recognized as a major causal factor and a more reliable indicator of CVD and atherosclerosis risk than LDL ("bad") cholesterol.

The Lifestyle Panel, available from BostonHeart Diagnostics, is another example of an advanced lipid panel that assesses cardiovascular risk. This panel includes a basic lipid profile, hs-CRP (explained below), HDL Map, and Cholesterol Balance tests. This panel provides information regarding high-density lipoprotein (HDL, or "good" cholesterol) populations, endogenous production of cholesterol, and gastrointestinal absorption of cholesterol to help stratify atherosclerotic CVD risk and understand the mechanisms behind a patient's dyslipidemia.

Inflammatory Markers

High-sensitivity C-reactive protein (hs-CRP) is a marker of inflammation that predicts the incidence of heart attack, stroke, peripheral arterial disease, and sudden cardiac death. Hs-CRP levels of less than 1, 1-3, and greater than 3 mg/L are associated with low, moderate, and high cardiovascular risks, respectively. (10)

Oxidative modifications of LDL are an early driving factor of atherosclerosis. Oxidized LDL (oxLDL) represents this population of LDL cholesterol in the blood vessels and is used to assess cardiovascular oxidative stress, inflammation, and plaque formation.

Elevated homocysteine, especially in the presence of other elevated inflammatory markers, is associated with a greater number of diseased arteries and an increased risk of CVD and neurological conditions.

Trimethylamine N-oxide (TMAO) is a metabolic byproduct of gut microbes when they consume certain animal foods. Elevated levels are related to an increased risk of CVD. A stool microbiome analysis may be warranted to follow up on high levels to assess for gut dysbiosis as an underlying cause.

Diabetes Panel

A diabetes panel, including blood glucose, insulin, and hemoglobin A1c, comprehensively evaluates glucose metabolism and screens for dysglycemia and diabetes.

Functional Medicine Treatment Protocol for Post-Stroke Recovery

Conventional treatment following a stroke generally falls into three therapeutic approaches (4):

1. Emergency pharmacologic or surgical care given immediately after a stroke to minimize brain injury
2. Treatment to prevent recurrent stroke
3. Rehabilitation, including physical, occupational, speech, vocational, and psychological therapies, to improve disabilities resulting from stroke

These conventional therapies are equally crucial as functional medicine recommendations and should be incorporated into an integrative treatment plan to maximize patient success in recovery. In addition, targeted dietary modifications, natural supplementation, and CIM modalities can expedite the healing process to help patients gain more independence and achieve the highest quality of life.

Therapeutic Diet and Nutrition Considerations Post-Stroke

Sustained neurological deficits after stroke can make it difficult to eat and drink safely and meet required nutrient goals. Working with a trained dietician or nutritionist can help patients get the nutrition they need to prevent malnutrition and slow recovery.

A heart-healthy diet should be recommended for patients at high risk for or recovering from a stroke. This nutritional approach emphasizes moderating the intake of added sugars, saturated fats, alcohol, and sodium; and replacing ultra-processed foods with a wide variety of fruits, vegetables, legumes, whole grains, unsaturated fats, and lean proteins. Refinement towards a more plant-based or Mediterranean-type diet helps reduce damage to blood vessels and optimize blood pressure, blood sugar, and cholesterol. (11)

Patients should be encouraged to eat a wide variety of these foods daily (11):

• Vegetables of different types and colors and low-glycemic index fruits contain important nutrients like fiber, magnesium, potassium, and polyphenols for heart health. A higher intake of fruit and vegetables, particularly apples, citrus, cruciferous vegetables, and green leafy vegetables, is associated with a dose-dependent decrease in the risk of stroke (12).
• Whole grains: amaranth, barley, brown rice, buckwheat, bulgur, corn, millet, oats, quinoa, and whole wheat
• Lean sources of protein: grass-fed and organic meat, poultry, fish, eggs, tofu, nuts, seeds, and legumes

In contrast, limit and avoid the following foods, which can lead to weight gain; elevated blood sugar, cholesterol, and blood pressure; and contribute to cardiovascular inflammation (11):

• Highly processed foods, including fast food meals, pre-packaged snacks, breakfast cereals, energy bars, and candy
• Alcohol
• Refined and added sugars found in soda, energy drinks, candy, baked goods, granola bars, and desserts
• Processed meats: bacon, bologna, hot dogs, salami, sausage
• Refined grains: white bread, white flour, white pasta, white rice, and packaged crackers and cookies

Supplements Protocol for Post-Stroke Recovery

Targeted nutrient and herbal therapy can be highly beneficial for post-stroke management. Here are some examples of evidence-based dietary and herbal supplements that functional medicine providers routinely recommend to their patients.

Multivitamin

A high-quality multiple vitamin and mineral complex serves as a foundation for supplementing essential micronutrients required for healing and preventing disease, and correcting common nutrient deficiencies observed in stroke patients. Vitamins and minerals of significant importance for post-stroke patients include vitamin D, B vitamins, magnesium, and vitamin C.

Dose: per label instructions daily

Duration: Ongoing

Alpha-Lipoic Acid (ALA)

ALA is a potent antioxidant routinely used in treating diabetic neuropathy for its neurorestorative properties. Research suggests ALA can also be a beneficial intervention in treating acute ischemic stroke after reperfusion therapy. Studies have observed a reduced risk of hemorrhagic transformation and early neurological deterioration and a higher occurrence of early clinical improvement in patients supplementing with ALA. (13)

Dose: 600 mg daily

Duration: 3-12 months

Citicoline

Citicoline is a well-absorbed and highly bioavailable source of choline, known to enhance brain and nerve function. Long-term treatment with citicoline is safe and effective in supporting neurogenesis and repair, improving post-stroke cognitive decline, and enhancing patients' functional recovery.

Dose: 500-1,000 mg twice daily

Duration: 6-12 months

Ginkgo biloba

Ginkgo biloba demonstrates antioxidant and vasoactive properties, making it a popular herb for supporting neurological and psychiatric disorders. This 2018 study studied ginkgo specifically for post-stroke recovery and found that dosing it with aspirin alleviated cognitive and neurological deficits after ischemic stroke compared to aspirin monotherapy.

Dose: 450 mg daily

Duration: 1-6 months

Complementary and Integrative Medicine Therapies To Consider Post-Stroke

The World Health Organization recommends acupuncture as a complementary strategy for improving stroke care and treatment. Clinical trial and meta-analysis findings have demonstrated acupuncture's efficacy in improving balance, reducing muscle spasticity, and increasing muscle strength and general well-being in post-stroke patients. The mechanisms behind these outcomes are believed to be related to acupuncture's ability to promote central nervous system neurogenesis, regulate cerebral blood flow, regulate neurochemicals, and improve nerve signaling and memory. (14)

Hyperbaric oxygen therapy (HBOT) involves the delivery of pure oxygen in a pressurized environment. Injured tissues have a higher oxygen demand, and HBOT increases the amount of oxygen the blood can carry to assist recovery. This 2018 systematic review concluded that HBOT significantly improves physiologic measures without causing cerebral toxicity to improve clinical outcomes in patients with severe traumatic brain injury. More specifically to stroke, a 2020 retrospective analysis observed significant improvement in all cognitive domains in ischemic and hemorrhagic stroke survivors undergoing HBOT.

When to Retest Labs

Clinically significant improvements in post-stroke patients have been seen as early as four weeks after initiation of CIM. Patients with diabetes, high blood pressure, and/or high cholesterol should have the appropriate cardiometabolic labs repeated between 4-12 weeks after initiating interventional therapies to assess the patient's response to therapy and modify as needed.

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Summary

Functional medicine practitioners can help post-stroke patients by recommending a combination of CIM modalities, encompassing nutritional therapy, dietary and botanical supplements, acupuncture, and hyperbaric oxygen therapy. Combined with conventional rehabilitation strategies, this integrative approach helps patients achieve improved functionality, neurologic function, and quality of life.