during functional activities to create lasting permanent changes. physical therapy is effective for recovery of function and mobility after stroke. occupational therapy is involved in training to help relearn everyday activities known as the activities of daily living (adls) such as eating, drinking, dressing, bathing, cooking, reading and writing, and toileting. approaches to helping people with urinary incontinence include physical therapy, cognitive therapy, and specialized interventions with experienced medical professionals, however, it is not clear how effective these approaches are at improving urinary incontinence following a stroke. treatment of spasticity related to stroke often involves early mobilizations, commonly performed by a physiotherapist, combined with elongation of spastic muscles and sustained stretching through various different positions. gaining initial improvement in range of motion is often achieved through rhythmic rotational patterns associated with the affected limb. after full range has been achieved by the therapist, the limb should be positioned in the lengthened positions to prevent against further contractures, skin breakdown, and disuse of the limb with the use of splints or other tools to stabilize the joint. cold in the form of ice wraps or ice packs have been proven to briefly reduce spasticity by temporarily dampening neural firing rates. electrical stimulation to the antagonist muscles or vibrations has also been used with some success. physical therapy is sometimes suggested for people who experience sexual dysfunction following a stroke. interventions for age-related visual problems in patients with stroke with the prevalence of vision problems increasing with age in stroke patients, the overall effect of interventions for age-related visual problems is currently uncertain. it is also not sure whether people with stroke respond differently from the general population when treating eye problems. further research in this area is needed as current body of evidence is very low quality. speech and language therapy speech and language therapy is appropriate for people with the speech production disorders: dysarthria and apraxia of speech, aphasia, cognitive-communication impairments, and problems with swallowing. speech and language therapy for aphasia following stroke compared to no therapy improves functional communication, reading, writing and expressive language. there may be benefit in high intensity and high doses over a longer period, but these higher intensity doses may not be acceptable to everyone. people who have had a stroke may have particular problems, such as dysphagia, which can cause swallowed material to pass into the lungs and cause aspiration pneumonia. the condition may improve with time, but in the interim, a nasogastric tube may be inserted, enabling liquid food to be given directly into the stomach. if swallowing is still deemed unsafe, then a percutaneous endoscopic gastrostomy (peg) tube is passed and this can remain indefinitely. swallowing therapy has mixed results as of 2018. devices often, assistive technology such as wheelchairs, walkers and canes may be beneficial. many mobility problems can be improved by the use of ankle foot orthoses. physical fitness a stroke can also reduce people's general fitness. reduced fitness can reduce capacity for rehabilitation as well as general health. physical exercises as part of a rehabilitation program following a stroke appear safe. cardiorespiratory fitness training that involves walking in rehabilitation can improve speed, tolerance and independence during walking, and may improve balance. there are inadequate long-term data about the effects of exercise and training on death, dependence and disability after a stroke. the future areas of research may concentrate on the optimal exercise prescription and long-term health benefits of exercise. the effect of physical training on cognition also may be studied further. the ability to walk independently in their community, indoors or outdoors, is important following stroke. although no negative effects have been reported, it is unclear if outcomes can improve with these walking programs when compared to usual treatment. other therapy methods some current and future therapy methods include the use of virtual reality and video games for rehabilitation. these forms of rehabilitation offer potential for motivating people to perform specific therapy tasks that many other forms do not. while virtual reality and interactive video gaming are not more effective than conventional therapy for improving upper limb function, when used in conjunction with usual care these approaches may improve upper limb function and adl function. there are inadequate data on the effect of virtual reality and interactive video gaming on gait speed, balance, participation and quality of life. many clinics and hospitals are adopting the use of these off-the-shelf devices for exercise, social interaction, and rehabilitation because they are affordable, accessible and can be used within the clinic and home. mirror therapy is associated with improved motor function of the upper extremity in people who have had a stroke. other non-invasive rehabilitation methods used to augment physical therapy of motor function in people recovering from a stroke include transcranial magnetic stimulation and transcranial direct-current stimulation. and robotic therapies. constraint‐induced movement therapy (cimt), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice may be effective in improving upper limb function. however, further primary research, specifically of cimt, mental practice, mirror therapy and virtual reality is needed. orthotics walking with an orthosis after a stroke clinical studies confirm the importance of orthoses in stroke rehabilitation. the orthosis supports the therapeutic applications and also helps to mobilize the patient at an early stage. with the help of an orthosis, physiological standing and walking can be learned again, and late health consequences caused by a wrong gait pattern can be prevented. a treatment with an orthosis can therefore be used to support the therapy. self-management a stroke can affect the ability to live independently and with quality. self-management programs are a special training that educates stroke survivors about stroke and its consequences, helps them acquire skills to cope with their challenges, and helps them set and meet their own goals during their recovery process. these programs are tailored to the target audience, and led by someone trained and expert in stroke and its consequences (most commonly professionals, but also stroke survivors and peers). a 2016 review reported that these programs improve the quality of life after stroke, without negative effects. people with stroke felt more empowered, happy and satisfied with life after participating in this training. prognosis disability affects 75% of stroke survivors enough to decrease their ability to work. stroke can affect people physically, mentally, emotionally, or a combination of the three. the results of stroke vary widely depending on size and location of the lesion. physical effects some of the physical disabilities that can result from stroke include muscle weakness, numbness, pressure sores, pneumonia, incontinence, apraxia (inability to perform learned movements), difficulties carrying out daily activities, appetite loss, speech loss, vision loss and pain. if the stroke is severe enough, or in a certain location such as parts of the brainstem, coma or death can result. up to 10% of people following a stroke develop seizures, most commonly in the week subsequent to the event; the severity of the stroke increases the likelihood of a seizure. an estimated 15% of people experience urinary incontinence for more than a year following a stroke. 50% of people have a decline in sexual function (sexual dysfunction) following a stroke. emotional and mental effects emotional and mental dysfunctions correspond to areas in the brain that have been damaged. emotional problems following a stroke can be due to direct damage to emotional centers in the brain or from frustration and difficulty adapting to new limitations. post-stroke emotional difficulties include anxiety, panic attacks, flat affect (failure to express emotions), mania, apathy and psychosis. other difficulties may include a decreased ability to communicate emotions through facial expression, body language and voice. disruption in self-identity, relationships with others, and emotional well-being can lead to social consequences after stroke due to the lack of ability to communicate. many people who experience communication impairments after a stroke find it more difficult to cope with the social issues rather than physical impairments. broader aspects of care must address the emotional impact speech impairment has on those who experience difficulties with speech after a stroke. those who experience a stroke are at risk of paralysis which could result in a self disturbed body image which may also lead to other social issues. 30 to 50% of stroke survivors develop post-stroke depression, which is characterized by lethargy, irritability, sleep disturbances, lowered self-esteem and withdrawal. depression can reduce motivation and worsen outcome, but can be treated with social and family support, psychotherapy and, in severe cases, antidepressants. psychotherapy sessions may have a small effect on improving mood and preventing depression after a stroke, however psychotherapy does not appear to be effective at treating depression after a stroke. antidepressant medications may be useful for treating depression after a stroke. emotional lability, another consequence of stroke, causes the person to switch quickly between emotional highs and lows and to express emotions inappropriately, for instance with an excess of laughing or crying with little or no provocation. while these expressions of emotion usually correspond to the person's actual emotions, a more severe form of emotional lability causes the affected person to laugh and cry pathologically, without regard to context or emotion. some people show the opposite of what they feel, for example crying when they are happy. emotional lability occurs in about 20% of those who have had a stroke. those with a right hemisphere stroke are more likely to have an empathy problems which can make communication harder. cognitive deficits resulting from stroke include perceptual disorders, aphasia, dementia, and problems with attention and memory. a stroke survivor may be unaware of their own disabilities, a condition called anosognosia. in a condition called hemispatial neglect, the affected person is unable to attend to anything on the side of space opposite to the damaged hemisphere. cognitive and psychological outcome after a stroke can be affected by the age at which the stroke happened, pre-stroke baseline intellectual functioning, psychiatric history and whether there is pre-existing brain pathology. epidemiology stroke deaths per million persons in 2012: 58–316 317–417 418–466 467–518 519–575 576–640 641–771 772–974 975-1,683 1,684–3,477 disability-adjusted life year for cerebral vascular disease per 100,000 inhabitants in 2004: no data <250 250–425 425–600 600–775 775–950 950–1125 1125–1300 1300–1475 1475–1650 1650–1825 1825–2000 >2000 stroke was the second most frequent cause of death worldwide in 2011, accounting for 6.2 million deaths (~11% of the total). approximately 17 million people had a stroke in 2010 and 33 million people have previously had a stroke and were still alive. between 1990 and 2010 the number of strokes decreased by approximately 10% in the developed world and increased by 10% in the developing world. overall, two-thirds of strokes occurred in those over 65 years old. south asians are at particularly high risk of stroke, accounting for 40% of global stroke deaths. incidence of ischemic stroke is ten times more frequent than haemorrhagic stroke. it is ranked after heart disease and before cancer. in the united states stroke is a leading cause of disability, and recently declined from the third leading to the fourth leading cause of death. geographic disparities in stroke incidence have been observed, including the existence of a "stroke belt" in the southeastern united states, but causes of these disparities have not been explained. the risk of stroke increases exponentially from 30 years of age, and the cause varies by age. advanced age is one of the most significant stroke risk factors. 95% of strokes occur in people age 45 and older, and two-thirds of strokes occur in those over the age of 65. a person's risk of dying if he or she does have a stroke also increases with age. however, stroke can occur at any age, including in childhood. family members may have a genetic tendency for stroke or share a lifestyle that contributes to stroke. higher levels of von willebrand factor are more common amongst people who have had ischemic stroke for the first time. the results of this study found that the only significant genetic factor was the person's blood type. having had a stroke in the past greatly increases one's risk of future strokes. men are 25% more likely to develop strokes than women, yet 60% of deaths from stroke occur in women. since women live longer, they are older on average when they have their strokes