By Julie Anderson
Omaha World-Herald, Neb.
OMAHA, Neb. 鈥� Andrea Kuester, then a fit, healthy 38-year-old, had just gone upstairs to check on her napping 2-year-old son, Bryce.
Not long after his wife went upstairs, Ryan Kuester heard banging on the upper floor of their west Omaha home, like the racket his son made when he woke up and kicked the wall through his crib slats.
He found his son asleep. He tried to open the door to the bathroom in their main bedroom but met resistance and spied red hair on the floor. With the help of their two young daughters, who initially thought their mom was playing around, he eased the door open and called 911.
Emergency responders told him they suspected his wife had suffered a stroke and took her to the Nebraska Medical Center.
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In the four years since her collapse on Feb. 21, 2021, Andrea Kuester has battled back from having no movement in her right arm or leg to walking a mile and a half, aided only by a single-point cane. She continues to make gains through outpatient therapy at Madonna Rehabilitation Hospitals in Omaha and on her own at home.
鈥淓very day is progress,鈥� she said.
But Kuester, now 43, is among a growing number of younger adults suffering strokes over roughly the past two decades, both in the U.S. and globally.
While the increase appears to have tapered in the last four years, some 15% of strokes since the early 2000s have occurred in people ages 18 to 50, studies indicate.
That has resulted in 120,000 Americans under 50 and some 2 million young adults worldwide suffering strokes each year, in contrast to a decreasing incidence of stroke among older adults. Strokes among those 45 to 64 also are on the rise, with more than 15% occurring in that age group.
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鈥淚t鈥檚 actually a phenomenon that鈥檚 been going on worldwide and is not really that well understood,鈥� said Dr. Samuel Bierner, Madonna鈥檚 Medical Director of Acute Rehabilitation.
With younger stroke patients coming in and older patients working longer, best practices in stroke rehabilitation have evolved in recent years to focus on getting people back to life roles that may include work and parenting.
That includes a strong push to start rehabilitation as soon as patients are medically stable, often within the first few days of the incident. For those who are able, it鈥檚 also likely to be more intense and to continue longer, as it has in Kuester鈥檚 case.
鈥淲e鈥檙e trying to push the people who are able to do more, so they get more endurance training and benefit from the activity,鈥� Bierner said. Animal studies, for instance, have produced some good evidence that increased aerobic activity in the early period after a stroke helps with recovering brain function.
One fairly new approach is high-intensity gait training, which involves pushing people to raise their heart rates closer to their maximum. Madonna has joined other groups in a study investigating the training, in which patients wear portable heart rate monitors while exercising.
Amy Goldman, Madonna鈥檚 stroke program manager, said research indicates that getting patients to between 70% to 85% their capacity is highly effective in improving walking, which translates to improved balance and ability to do activities of daily living.
In addition to Madonna鈥檚 Omaha and Lincoln campuses, there are four other Commission on Accreditation of Rehabilitation Facilities (CARF) Stroke Specialty Programs in Nebraska: Regional West Medical Center Acute Rehabilitation Unit in Scottsbluff; Bryan Medical Center Inpatient Rehabilitation Unit in Lincoln; and Immanuel Rehabilitation Institute and Methodist Hospital Rehabilitation Center in Omaha.
They follow the same guidelines for comprehensive rehabilitation, which includes speech, recreation and other therapies.
Madonna, thanks to donors, has some advanced technologies, including a Lokomat, a gait trainer that allows patients to walk through a virtual environment and navigate obstacles, Goldman said. Armeo devices allow patients to practice fine motor skills with their upper extremities, such as cracking an egg into a skillet.
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Goldman, chair of the Nebraska State Stroke Task Force鈥檚 rehabilitation committee, said the risk factors among younger adults are similar to those among older ones, including hypertension, diabetes, high cholesterol, smoking, overweight and obesity and sedentary lifestyles.
Bierner noted, however, that modifiable risk factors such as obesity also are on the rise among younger patients. COVID-19 infections, with their impact on clotting, added to the stroke toll among younger patients during the height of the pandemic.
Risk factors that are unique to younger patients, Goldman said, are genetic conditions, pregnancy and postpartum issues and lifestyle factors that go beyond poor diet and lack of exercise to include excessive alcohol use and illicit drug use.
Chronic migraine headaches in that group also are a risk factor and can signal undiagnosed high blood pressure, also a risk factor.
鈥淭his is not just an old person disease,鈥� she said. 鈥淚t can happen at any time to anyone at any age.鈥�
That means health care providers need to do more to prevent strokes, Goldman said, including making sure people know the risk factors.
Women need to take precautions around pregnancy, recognizing genetic conditions that predispose them to clotting and making sure to monitor for preeclampsia, which is associated with high blood pressure, both during pregnancy and afterward.
It also means making sure people know the signs of stroke, she said. People in general are more attuned to recognizing the signs of a heart attack than of stroke.
The American Stroke Association uses the acronym FAST, which stands for Face drooping or twisting; Arm weakness; Speech difficulty; Time to call 911. Some organizations extend it to BE FAST, which includes Balance, as in sudden loss of balance or coordination; and Eyes, representing sudden trouble seeing in one or both eyes.
Kuester, on the other hand, had no risk factors for stroke and no warning signs. After putting her through a battery of tests, doctors listed the cause as 鈥渋nconclusive.鈥�
鈥淭he most unhealthy thing my wife did was drink coffee now and then,鈥� Ryan Kuester said. 鈥淔rom a profiling standpoint, you wouldn鈥檛 have picked her out from a lineup to drop from a stroke.鈥�
Her stroke landed her in critical care for a couple of weeks and a less intensive unit for another week and a half. During the course of treatment, she underwent a craniotomy to reduce swelling and pressure on her brain.
鈥淪he made a very miraculous recovery, because the prognosis wasn鈥檛 positive,鈥� Ryan Kuester said.
She got into therapy right away, undergoing acute inpatient rehabilitation at Madonna for two months and completing an additional three months at QLI, which specializes in rehabilitation for brain and spinal cord injuries. She has continued outpatient therapy at Madonna off and on.
Both her right leg and arm have gotten stronger, although she still has a limp and struggles to find some words. 鈥淔iller words are a bugger,鈥� Kuester said.
She said she definitely noticed that her therapists were working her hard. She recalls telling her husband after he picked her up from outpatient sessions that therapy had kicked her butt.
Kuester, an orthopedic physician鈥檚 assistant before the stroke, also has continued therapy at home, including following the instructions sent home by Madonna between sessions there.
Recently, the couple has been exploring vagus nerve stimulation, which the Food and Drug Administration has approved for stroke.
The device is implanted in the chest and connected to the vagus nerve in the neck. The stimulation provided by the device, according to the Mayo Clinic, can help create new pathways in the brain as a person performs exercises and help them regain function in the hand or arm, even years after a stroke.
Michelle McKibbon of Papillion, who suffered a stroke in August at age 45, also noticed the intensity while undergoing acute inpatient rehabilitation at Madonna. She lost the use of her left arm, hand and leg and had to learn how to walk again. She also lost part of her peripheral vision. Part of it returned while she was running on a treadmill and 鈥減umping all that oxygen鈥� through her body.
鈥淭he more active you are, the more results you鈥檒l see in your recovery,鈥� said McKibbon, who now has regained most of her eyesight and is back to running at home.
She is scheduled to continue her outpatient therapy, where she has been working on getting back range of motion in her arm and hand, until mid-month. She, too, has continued her therapy at home. She and her husband bought a rowing machine, which helps with her arm and grip strength, and they take walks.
In her case, doctors attributed her stroke to high blood pressure. She had had frequent headaches and water retention, but she typically chalked it up to the weather or to being tired or stressed. She worked in accounting, a deadline-driven field, and sat for long periods. She didn鈥檛 take a lot of time off and wasn鈥檛 a regular at the doctor鈥檚 office.
鈥淚 had never really realized that younger people could have strokes,鈥� McKibbon said. 鈥淚 always thought that was something that could happen to you later in life.鈥�
But she was standing in her kitchen last August when she started feeling numbness and tingling in her left arm and leg. The leg gave out and she fell on the floor. Her husband, who has first responder training, came up from the basement. Her face started drooping and her speech was garbled so he called 911.
Meanwhile, she got up and walked back to her bedroom and started trying to get ready to go to work but began feeling the same symptoms. She saw flashing lights and felt so unwell she had to lie down on her bed. Paramedics arrived and took her to Creighton University Medical Center-Bergan Mercy, where the symptoms returned and she suffered a full-blown stroke.
McKibbon said she is grateful to her husband鈥檚 employer, the Nebraska Game and Parks Commission, for their flexibility and understanding, which allowed him to accompany her to her therapy and appointments.
She now prioritizes her health and tells her story in the hope that it will help or inspire others.
鈥淚f you keep working at it, you can keep gaining,鈥� McKibbon said.
Kuester, too, has made a point of sharing what she has learned. She has presented to first and second year physical therapy students at the University of Nebraska Medical Center so they can see the impacts of stroke first hand. She also spoke at the Women and Stroke Conference hosted by the Nebraska Stroke Task Force at UNMC in September.
Recently, she received the annual Stephanie Wever Courage Award from the Nebraska Stroke Association, which honors individuals who have shown 鈥渆xceptional strength, resilience, and courage in their journey after experiencing a stroke.鈥�
Said her husband: 鈥淪he does everything with determination and a smile. I can鈥檛 say that I would be the same. ... That鈥檚 just who she is.鈥�
鈥淚 had never really realized that younger people could have strokes. I always thought that was something that could happen to you later in life.鈥�
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