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Aims

  • Consider the roles of a variety of health professionals in the multidisciplinary approach to managing a person with a stroke.
  • Consider the pathophysiology of ischaemic stroke.

Key concepts

  • Describe the roles of doctors, nursing staff and allied health workers in the management of stroke.
  • Describe the sequence of events that occur during ischaemic stroke at the molecular and cellular level.
  • Progress reports for projects and assignments

Presentations on stroke and stroke rehabilitation

Common impairments, limitations and complications after stroke

  • What are the common impairments immediately following stroke?
    • Arm/hand/leg weakness
    • Facial weakness
    • Sensory loss (spinothalamic)
    • Dysarthria
    • Dyspraxia
    • Aphasia
    • Homonymous visual field defect
    • Neglect
    • Sensory loss (proprioception)
    • Cognitive impairment
    • Visuospatial dysfunction
    • Balance problems
    • Motor planning (can't perform tasks even though you can think about them)
  • What are the common limitations of physical activity in the initial phase following a stroke?
    • Stair climbing
    • Bathing
    • Walking
    • Dressing
    • Toileting
    • Transferring between hospitals
    • Feeding
    • Urinary and/or faecal incontinence
  • What are the common complications that patients with stroke may develop in hospital?
    • Medical problems (e.g. chest pain, gastro-intestinal haemorrhage)
    • Pneumonia
    • Confusion
    • General pain
    • Falls
    • Urinary tract infection
    • Chest infection
    • Pressure sore / skin break
    • Other infections
    • Depression
    • Anxiety
    • Emotionalism
    • Shoulder pain
    • Recurrent stroke
    • Epileptic seizure
    • Venous thromboembolism
  • What are the likely causes of death within the first few weeks following a stroke?
    • 13% die within 30 days of stroke
    • Initial event: 1) Neuronal damage e.g. brainstem infarct; 2) Cerebral edema, raised ICP, herniation
    • Later: aspiration pneumonia, intracerebral haemorrhage, recurrent stroke + MI - DVT, Sepsis - UTI, pressure sores, herniation - medulla oblongata

Rehabilitation of patients after stroke

  • Where should patients be cared for immediately following a stroke?
    • General medical ward v stroke unit
    • Stroke unit lowers mortality by 17% compared to being in a general ward
    • Stroke unit = rehabilitation, multidisciplinary team, etc; dedicated to stroke
  • Where should the GP send this patient? The literature would strongly support transfer, without further delay, to a stroke unit, where he can be appropriately investigated (a computed tomography [CT] or magnetic resonance imaging [MRI] scan is essential) and treated. The positive value of stroke units was confirmed by the meta-analysis of reported as part of the Cochrane database. Comparing patients treated in a stroke unit with those treated in a general medical ward, after a median follow-up of one year, these researchers found that, with the former, there was a median reduction in the odds of mortality of 17%, a 31% lower odds of "death or dependency", and a 25% lower odds of "death and institutionalisation". Interestingly, more recent work suggests that the difference in mortality persists for 5 years, and even 10 years, after the acute event. Unfortunately, despite the clear advantages of treatment in a dedicated stroke unit, we do not know which specific aspect makes the critical difference. In the meta-analysis, the definition of "dedicated stroke unit" was broad and included units that concentrated on acute management and generally discharged patients within 7 days (early rehabilitation being an important component of the care), units which accepted patients after about 7 days and whose main emphasis was rehabilitation, and combinations of the above. Rehabilitation was therefore one common component of all units, with key elements being a coordinated, multidisciplinary team with specific expertise in stroke, a physician with a special interest or dedication to stroke, agreed protocols for best practice and outcome audits, and educational programs for staff, patients and carers.
  • When should rehabilitation assessment occur following a stroke?
    • It is strongly recommended that a rehabilitation assessment is undertaken within 24–48 hours of admission to a stroke unit. Early evaluation of swallowing and the establishment of safe feeding is critical, as aspiration (which is silent in up to 40% of patients) may lead to pneumonia and increased mortality. Secondary physical injury can be avoided by proper handling of flaccid or hypertonic limbs, and precautions to prevent falls are essential, particularly in patients with non-dominant-hemisphere strokes with associated neglect (loss of the ability to respond to objects or sensory stimuli located on the side of the body affected by the stroke).
  • Key issues in the acute phase of stroke
    • Patients should be admitted (if possible) to specialised stroke units
    • A comprehensive interdisciplinary rehabilitation assessment should take place within 24–48 hours
    • Establishment of safe feeding lowers the risk of aspiration pneumonia and decreases mortality rate
  • Where should rehabilitation be provided?

Selection of patients for rehabilitation

  • If in hospital: then stroke unit
  • Whether to send home: 1) dependence of patient 2) available support at home
  • Rehab programs: 1) inpatient (stroke unit, rehab centre 2) outpatient: speech therapy, physio 3) home based: program developed and implemented at home (greater patient satisfaction, but more stress of family)
  • About 20% of patients die in the first month after stroke, and more than half of the survivors will require specialist rehabilitation. Once the patient's condition stabilises medically, there is less need for the facilities of the acute hospital, and the focus of the rehabilitation program moves to improving function and independence, and preparing the stroke survivor and his or her carers for life after discharge in the context of their previous health, home and family situation, avocational and vocational needs.
  • Rehabilitation is, however, an expensive and limited resource, and its success depends on careful selection of patients. There are thus vital questions to answer while the patient is in the acute ward. Firstly, is the patient medically stable and fit for a rehabilitation program, and is it possible to set realistic rehabilitation goals? If the answer to these is no, then it is better to look at other options for the patient. For example, medical instability is best managed by a longer stay in a medical ward, and, if the patient is assessed as unlikely to make any functional improvement, residential placement may be the best option. In the latter case, close liaison with the geriatric team is essential, particularly for older patients with severe dementia.
    • Neither of these options, of course, excludes later rehabilitation (there is some evidence, for example, that rehabilitation may still be beneficial several years after a stroke) and regular monitoring by the rehabilitation physician is often appropriate to select those patients who may require intermittent therapy to maintain or improve function.
  • Where should rehabilitation be provided
    • Once the decision has been made to offer rehabilitation, the second question to be answered is where should it be provided? Options include specialist inpatient, outpatient or home-based services, and all of these can provide high quality rehabilitation programs. Important factors to take into account include the dependence of the patient (the need for 24-hour nursing care or supervision usually precludes home management), and how much support is available at home.
    • The wish of the patient and family must also always be respected; patients who live in extended families often prefer to be in the home environment, particularly (in the Australian context) if they speak limited English.
    • Several randomised controlled trials have been published in the past five years comparing home-based rehabilitation programs with rehabilitation in hospital, and these have been the subject of a systematic review that showed no statistically significant difference between the two approaches, either in terms of patient and carer outcomes or resource utilisation.
    • Nevertheless, some of the individual studies reviewed by the Cochrane Collaboration did show change: three studies suggested higher levels of patient satisfaction, and specifically reported that patients felt more involved in planning their rehabilitation programs if they were treated at home. In addition, one study reported the important finding that carers at home developed more "stress" at 6 months, but this was detected only by one of the three tools used (the 36-item Short-form Health Status survey [SF-36]), and the difference was not present at the 12-month follow up.
    • Of concern in this regard is a recent British study that found a higher mortality rate at 3, 6 and 12 months in patients receiving home-based rehabilitation than in those admitted to a stroke unit. However, patients in that study were transferred to home care shortly after admission to the acute hospital, whereas most Australian units provide inpatient and home-based rehabilitation sequentially. Another important aspect of that study was the definite difference in functional outcome found between the stroke unit, general ward and home therapy groups, with the greatest improvement occurring in patients treated in the stroke unit. Moreover, the groups also differed markedly in the median amount of therapy received during similar lengths of stay (eg, a total of 21.5 hours of physiotherapy in the stroke unit versus only 7.3 hours at home). Perhaps it is the amount of therapy that makes the difference, not where it is delivered?
    • Attempts to compare community-based (non-inpatient) programs with inpatient programs have been beset by wide variation in program definition, and the poor performance of standard outcome measures in this context. Any rehabilitation professional knows from experience that many carefully selected patients do well as outpatients.
    • Most of the evidence in favour of rehabilitation in the post-acute phase is based, as in the acute phase, on evaluation of a multidisciplinary program as a whole, or a particular discipline (eg, speech or occupational therapy) as an entity, rather than on the individual components or the philosophy of rehabilitation. For example, the Cochrane Collaboration is currently reviewing the large body of research comparing specific physiotherapy techniques (eg, the neurophysiological paradigms of Bobath and Brunnstrom and the "motor relearning" approach). Preliminary reports suggest that none is clearly superior for lower-limb function, but in many instances high-quality research is just not available. Lack of an evidence base should not stop us persevering with a technique that apparently helps while we await conclusive evidence.
    • Improvements in function after stroke are the result of a number of processes, including recovery of parts of the ischaemic penumbra (the potentially viable zone surrounding areas of cerebral infarction), resolution of cerebral oedema, neuroplasticity (parts of the brain on the same or opposite side may take on the functions of the damaged area), and the patient learning to compensate by using the unaffected parts of the body. Recovery is affected by the size of the stroke, and by any pre-existing comorbidities or dementia, and is likely to be maximal within the first three months. Determining the prognosis is always difficult, but is usually possible by six months after the stroke, and often much earlier. The Oxfordshire Classification of Stroke is a clinically based classification which can assist in prognostication for survival and dependence, but it is important not to provide a too-confident prediction.

Key issues in the specialised rehabilitation phase

  • Rehabilitation is a limited resource and needs to be offered to selected patients
  • Comorbidities such as depression and obstructive sleep apnoea may affect the outcome
  • A spectrum of inpatient, home-based and non-inpatient resources should be available
  • What is the role of the general practitioner in rehabilitation following stroke?
    • The GP is always a critical member of the team, and in rural hospitals may be the treating doctor during the inpatient stay. The GP's role becomes paramount as discharge approaches. Many discharged patients face reduced mobility and loss of independence, which may lead to anger, frustration, changes in body image and feelings of reduced self-worth. Immobility may lead to constipation, incontinence and weight gain, which may have significant adverse effects on comorbidities such as diabetes and osteoporosis. The GP must deal with all of these, as well as reinforcing and monitoring secondary prevention, including promoting healthy lifestyle changes, and answering the perennial question "Will it happen again?".
    • The GP is also the trusted person, called on to counsel patients and partners about private issues, such as interpersonal and sexual relationships. Advice will also be sought about vocational and recreational activities, shopping and social outings, and driving is often a source of contention. Australian guidelines suggest that, unless a patient's condition is complicated by epilepsy, driving can be permitted after 3 months, but the attending doctor must be convinced that this is safe for both the patient and the public, and, if there is any doubt, should have recourse to an assessment of driving ability by a trained occupational therapist. Thus, the GP holds the key to patients achieving a good quality of life — the ultimate goal of any rehabilitation program.
  • Prevent recurrence, improve QOL overall

Current knowledge regarding stroke

  • How common are strokes in the Australian population?
    • 53000 Australians per year, 7% of all deaths in Australia anually. Stroke kills more women than boob cancer and more men than prostate cancer.
    • Costs $555 million in the first year after a first time stroke, including direct and indirect costs. Per case = $18k. Recurrent strokes cost $22k per case. Lifetime cost of first ever stroke is $44k. Average stay in hospital is 28 days. Includes hospitalisation, rehabilitation, nursing hoes, and lost productivity.
    • There are no directly measured national data on the incidence of stroke in Australia (although we do know that cerebrovascular disease accounts for over 9% of all deaths). The best estimates available come from local registers that have been run for limited periods only.
    • First-ever stroke incidence rates (age- and sex-adjusted to the world population) range from 76 per 100,000 population in Perth during 1995–96 to 100 per 100,000 population in Melbourne during 1996–97 (Jamrozik et al. 1999, Thrift et al. 2000).
  • What are the short-term and long-term probabilities of death following a stroke?
    • 28 days - 28%
    • 1 year - 41%
    • 5 years - 60%
  • What factors affect the quality of life following stroke?
    • Problems include: Unilateral paralysis (esp. upper limb), speech and swallowing difficulties, cognitive impairment, depression and anxiety, personality changes.
    • Dependencies: Medications, gait aids, assistive technology and other aids, health professionals, families, carers; financial and social cost
    • Of those having a first-ever stroke, 80% are alive at 28 days and 63% are alive 1 year after their stroke (Thrift et al. 2000). About one in six survivors of a first-ever stroke have a recurrent stroke over the next 5 years (Hankey et al. 1998). Recurrent strokes have a similar 28-day survival rate to that of first-ever strokes.
    • Nearly all patients are disabled at the time of the stroke. There may be permanent paralysis of one side of the body, speech or swallowing difficulties, problems with memory, personality changes or a range of other difficulties. Depression and anxiety are common after stroke and many survivors have difficulty returning to their previous leisure activities (Burvill et al. 1995a, Burvill et al. 1995b). Recovery is most rapid in the early weeks and nearly complete, if it is to be so, within 6 months of the stroke. By the end of the first year, about half of all survivors of stroke remain dependent on others for activities of daily living (Hankey et al. 2002).
    • Among 30-day survivors of first-ever stroke, about half survive 5 years (Hankey et al. 2002). Of those who survive to 5 years, one-third have a disability and one in seven are in ongoing institutional care.
    • The majority of survivors are disabled at 3 and 12 months after stroke (Sturm et al. 2002).
    • Although physical independence and occupation are most severely affected, stroke survivors are disabled over a wide range of areas. These include mobility, social functioning, orientation and economic self-sufficiency. Stroke also carries emotional and behavioural consequences that can influence the effectiveness of rehabilitation, and have a severe impact on life satisfaction (Hochstenbach 2000). These psychological problems need to be treated too (White & Johnstone 2000).
    • Although problems in orientation are unlikely to be modifiable in most cases, much of poststroke disability may be improved. Care in a stroke unit for acute stroke will reduce impairment and disability. **Rehabilitation services may reduce disability in the areas of mobility, physical independence and social relationships by providing mobility and communication aids and modifying the environment. **Occupational therapy can reduce limitations to occupational participation. Stroke has a marked impact on quality of life. When assessing outcomes, it is important to measure quality of life in addition to death and disability, as people who have had a stroke may rate their quality of life as low even when they are able to perform activities of daily living (Teasell 2003).
  • What are the costs of stroke to the Australian community?
    • Stroke has been estimated to account for about 4% of the total costs of disease in Australia (AIHW & CHPE 1995).
    • The total first-year costs of all first-ever strokes in Australia during 1997 were estimated at $555 million and the lifetime costs at $1.3 billion (Dewey et al. 2001). This included direct service use, care-giver time, out-of-pocket payments, and production losses. The definition of stroke used does not include subarachnoid haemorrhage or transient ischaemic attack. The average cost per case in the first year of a first-ever stroke was $18,956; over a lifetime it was $44,428. In contrast, the average cost per case during the first year after recurrent stroke was $21,786. The average cost per rehabilitation admission was estimated to be $13,627. Rehabilitation (inpatient and outpatient) was the largest component of total cost during the first year after a first-ever stroke, amounting to $156 million (28%). In addition, community rehabilitation cost a further $10 million. Acute hospitalisation cost almost as much ($154 million, 28%), followed by nursing home care ($63 million, 11%).
  • What are the risk factors for stroke, and how common are they?
    • Age
    • Previous transient ischaemic attack or stroke
    • High blood pressure - 29% of Australians aged 25 years and over (about 3.6 million) had high blood pressure or were on blood-pressure-lowering medication in 1999–00 (AIHW 2002). This is the most important risk factor.
    • Tobacco smoking - 19% of Australians aged 14 years and over (about 3.1 million) smoked regularly in 2001 (AIHW 2002). A further 3.6% smoked occasionally.
    • Diabetes - 7.5% of Australians aged 25 years and over (an estimated 938,700) had diabetes in 1999–00 (AIHW 2002).
    • High blood cholesterol -50% of Australians aged 25 years and over (over 6 million) had high blood cholesterol levels in 1999–00 (AIHW 2002).
    • Atrial fibrillation
    • Narrowing of the carotid arteries (carotid stenosis).
    • Overweight/obesity - 60% of Australians aged 25 years and over (about 7.5 million) were overweight or obese in 1999–00 (AIHW 2002). Of these, 21% (2.6 million) were obese.
    • Sedentary lifestyle - 43% of Australians aged 18–75 years (around 5.7 million) did not undertake sufficient physical activity to achieve health benefits in 2000 (AIHW 2002).
  • How may recurrent strokes be prevented?
    • There is wide variation in the care given to people with stroke. This is due to resource availability, cost, access to services, preferences of patients and differences in medical practitioners, hospitals and governments, as well as poor evidence on the effectiveness of many aspects of stroke care (Hankey & Warlow 1999).
    • Effective interventions to treat stroke in the acute phase and to prevent the occurrence of subsequent stroke events are summarised below. There are some components of stroke care, such as physiotherapy, occupational therapy and other forms of rehabilitation, for which there is limited conclusive evidence; however, this does not mean they are ineffective.
  • Treatments to manage acute stroke include:
    • Organised care in a stroke unit by a multidisciplinary team (level 1 evidence)
    • Aspirin for acute ischaemic stroke (level 1 evidence)
    • Tissue plasminogen activator (tPA) given within 3 hours of onset of acute ischaemic stroke (level 1 evidence).
  • Measures for preventing recurrent stroke in patients with transient ischaemic attack (TIA) or stroke include:
    • Lowering of blood pressure (level 1 evidence)
    • Smoking cessation
    • Regular exercise
    • Antiplatelet drugs (aspirin, aspirin + dipyridamole, or clopidogrel) long-term for patients with normal heart rhythm (level 1 evidence)
    • Anticoagulation (warfarin) long-term for patients with atrial fibrillation (level 1 evidence)
    • Lowering of blood cholesterol with drugs (statins) in patients with established CHD (level 1 evidence)
    • Carotid endarterectomy for patients with severe narrowing of the internal carotid artery on the symptomatic side and who are fit for surgery
    • Tight control of diabetes
    • Weight control, if appropriate
    • A healthy diet.
  • Effective prevention is the most powerful strategy to reduce the burden of stroke. Rehabilitation and secondary prevention of recurrent stroke should begin on day 1 after stroke, as the risk of recurrent stroke is highest in the first 6 months after the event (Hankey et al. 1998, Hankey 2000).
  • The most important modifiable predictors of poor long-term outcomes (death, institutionalisation or disability) are low levels of physical activity before the stroke and subsequent recurrent stroke (Hankey et al. 2002).
  • Although the effectiveness of certain measures is well established, they are currently underused. Stroke units provide organised care with a multidisciplinary team including professionals such as neurologists, other doctors, nurses, physiotherapists, occupational therapists, speech pathologists, dietitians and social workers. This care is appropriate for all patients, but it is not currently widely available in Australia.
  • Similarly, only about 1 in 4 patients with transient ischaemic attack or stroke in whom long-term anticoagulant drugs are indicated actually receive this treatment (Hankey & Warlow 1999). Aspirin is likewise underused for secondary prevention of vascular disease (Mollison et al. 1999).
  • However, there is evidence that the care of people with heart disease and stroke problems improved during the 1990s, with more effort being directed to prevention (AIHW: Henderson et al. 2002). There have been significant rises in the prescription of blood pressure-lowering drugs, aspirin, anticoagulants and blood-cholesterol-lowering drugs.
  • General practitioners are also more likely than in the past to do check-ups and to provide counselling and advice to their patients with a history of heart disease or stroke. It is reasonable to assume that this involved discussions about the patients’ lifestyle and suggestions to change risk behaviours if indicated.

Roles within multidisciplinary teams for stroke management

  • Many issues need to be addressed in rehabilitation programs, whatever the environment. Rehabilitation will only be successful if the team, patient and carers cooperate to set interdisciplinary goals. Regular team and family meetings are thus mandatory. Cohesion is often aided by the appointment of a "key person", one member of the team who liaises with the family; this is also often less intimidating to family members.
  • Individual team members then bring their specific expertise to the rehabilitation goals.
  • Neurologist / Rehabilitation Physician
    • Usually leads the team and works closely with the nurses to deal with comorbidities, such as hypertension and diabetes, and to treat or prevent secondary complications, such as pressure areas and seizures (about 5% of patients will have a seizure in the first year after stroke). A further important complication is post-stroke depression, with a high incidence of more than 60% noted by Robinson et al nearly two decades ago. More recently, depression has been shown to affect the functional outcome of a stroke, perhaps providing a reason for more aggressive treatment of depression after a stroke. Anxiety may be even more common, but prescribing anxiolytics and hypnotics is rarely of benefit to these patients, even if they have a poor sleep pattern. The rehabilitation specialist also has an important role in the pharmacological treatment of spasticity, using drugs such as baclofen or dantrolene, or through nerve blocks, motor point injections or botulinum toxin injections. Various pain syndromes (which may include musculoskeletal trauma or complex regional pain syndrome) are common after stroke and require careful medical assessment and medical assessment and management.
  • Nursing Unit Manager and Clinical Nurse Consultant
    • Whilst nursing stroke patients in specialised units is becoming more commonplace there are many other contexts where stroke care is still carried out. Many of the factors identified in this section could be equally applied wherever stroke patients are cared for. Nursing people with stroke requires nurses with knowledge, skills and interest to deliver effective therapeutic care and rehabilitation, and requires education and training in stroke care. Stroke nurses focus on working in partnership with patients and their families, involving them in decision making and taking responsibility for their own recovery. Nurses take into account the holistic needs of the patient and family, involving the physical, psychological and social aspects of care. As each patient and family is unique, nurses consider the individual’s needs. **Stroke nursing is a continuous 24 hour process throughout the patient’s journey of care, wherever the setting.
  • Social Worker
    • Play an important role in evaluating a patient's premorbid state within his or her social network and society as a whole, and in determining what aspects were previously determinants of the patient's quality of life. Social workers often take on a critically important counselling role with the patient and next-of-kin, and link professionals in arranging and coordinating community resources before and after discharge. This task can be a complex nightmare for uninitiated family members.
  • Speech and Language Therapist
    • Deal with communication and motor production of speech, as well as chewing and swallowing.
  • Occupational Therapist
    • May take the lead in teaching independence in activities of daily living, guiding the patient (if improvement allows) through personal hygiene to domestic and community activities, but success in these domains will demand input from physiotherapists as well.
  • Physiotherapist
    • May focus on limb weakness, abnormal tone (flaccid or spastic) and balance, to meet the agreed aim of independent mobility, but need to work closely with occupational therapists to achieve this.
  • Neuropsychologist / Clinical Psychologist
    • Is an important member of a specialised stroke rehabilitation team, as cognitive deficits are common. These often include impaired memory and concentration, as well as difficulties in planning and problem solving. Personality changes are frequent. Damage to specific areas of the brain can lead to distinctive clinical syndromes, and their accurate definition is helpful to the team (eg, a frontal haemorrhage will often affect learned social inhibitions, emotional responses and control, while lesions of the parietal lobe, particularly in the non-dominant hemisphere, tend to impair perception and planning). A particularly formidable task, often delegated to neuropsychologists, is assessment of a patient's capacity to make a will, and there are few guidelines on which to base this difficult decision.

  • Distinction between occupational therapist and physiotherapist: occupational therapist is for regaining independence; physiotherapy is for regaining normal movement
  • Watch video of all the different roles in a stroke unit
  • Pharmacological management of stroke: thrombolysis (unless haemorrhage), warfarin (unless low platelets; especially in atrial fibrillation), diabetes control (metformin), hypertension control (frusemide), cholesterol control (statins), control of spasticity (baclofen), urinary incontinence control
  • Surgical: embolectomy
  • Rehabilitation is necessary as well - for a long time; it is still effective a long time after

Flowchart: Sequence of events in ischaemic stroke

IschaemicStrokeSequence.png

  • Brain can't be sustained on anaerobic metabolism, but can undergo anaerobic metabolism in pathology
  • Important transporters: Na-K ATPase, Ca-ATPase, Voltage-gated Ca channels (L-VOCC)
  • Note the NMDA receptor is involved in a positive feedback loop
  • Phospholipases are activated as part of a secondary messenger system involving calcium
  • Free radicals include superoxide, hydroxyl radicals and singlet oxygen