The effective treatment and rehabilitation of stroke patients requires a multidisciplinary team approach.
Healio O&P News April 1, 2004
According to the Centers for Disease Control and Prevention, stroke is the third leading cause of death in the United States, killing 283,000 people in the year 2000. On average, someone in the United States suffers a stroke every 45 seconds. Every 3.1 minutes someone dies of a stroke. It is the leading cause of serious long-term disability in the United States. A stroke survivor has a 20 percent chance of having another stroke within two years.
According to data collected from the American Heart Association, there are between 1 million and 1.5 million stroke deaths per year in China. In some areas of China, it is the leading cause of death. The incidence of stroke in China is four times that of acute myocardial infarction. Sixty-one percent of adult males and 7 percent of adult females in China smoke cigarettes.
In Canada, stroke is the fourth leading cause of death. There are more than 50,000 strokes each year, including 16,000 deaths.
The WHO defines stroke as “rapidly developing clinical signs of focal (or global) disturbance of cerebral function lasting more than 24 hours (unless interrupted by surgery or death) with no apparent cause other than of vascular origin.”
Depending on what kind of CVA and the area of the brain effected, patients will present with a range of sensory, motor, speech, behavioral and cognitive problems and therefore, multidisciplinary treatment and rehabilitation goals are tailored to individual needs.
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Types of stroke and warning signs
There are essentially two kinds of strokes — ischemic and hemorrhagic. Ischemic strokes, which are the majority of strokes, are the result of a disruption of blood flow to a portion of the brain. This usually stems from a blood clot in a blood vessel in the neck or brain, therefore causing cell damage in that area. Hemorrhagic strokes are the result of bleeding into the brain, causing injury to brain tissue.
Dara Jamieson MD and Ralph Sacco MS MD in a paper titled, Treating Stroke: How to Reduce the Damage, noted that the foundation for stroke treatment is the immediate recognition of symptoms followed by emergency care.
“The key for stroke treatment is to receive medical treatment in less than three hours,” wrote Sacco.
In the case of an ischemic stroke, the patient may be a candidate for intravenous clot-busting medications to preserve brain cells, improving short- and long-term outcomes.
Jamieson added that clot-busting drugs do not produce an immediate improvement. It takes about three months to see results.
“It is important to understand that damage from stroke is a continuous process,” she wrote. “The brain damage occurs in a cascade of different events … so several things may occur at different times.”
In a bleeding stroke, the chances of dying are greater and the treatment options are fewer. To clear the blood clots, surgery may be necessary.
The warning signs of a CVA are:
- Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
- Sudden confusion, trouble speaking or understanding
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden, severe headache with no known cause
Jamieson pointed out that one of the problems with stroke is that there is no accompanying pain; therefore, some people don’t think of it as an emergency situation.
Remarkably, approximately 80 percent of CVAs are due to lifestyle choices. Making changes in these behaviors can reduce or eliminate most of the risk factors. Risk factors are:
- Obesity/hyperlipidemia/physical inactivity
- Diabetes mellitus
- Coronary artery disease/atrial fibrillation
- Male gender
- Excessive alcohol
- Illegal drug abuse
Treatments and rehabilitation
A comprehensive treatment program implemented by a multidisciplinary team of professionals is crucial in the rehabilitative care of each patient. Team members may include physiatrists, physical and occupational therapists, nurses, speech pathologists, psychologists, orthotists and others. Additionally, medications, surgery and other modalities may be incorporated into the treatment plan.
The goals and treatment plan are usually based on the patient’s cognitive abilities, medical condition, functional ability, patient and family goals, expected functional outcome and prior level of functioning. Generally, goals focus on getting the patient as close as possible to the lifestyle they had prior to the stroke.
“Our main objective is to look at their level of functioning after the stroke and assess what their physical needs are with respect to recovery,” said Michael Lupinacci MD, medical director of the HealthSouth Rehabilitation Hospital of Mechanicsburg in Mechanicsburg, Pa. “Some may be ongoing and some may be complications from an acute illness. We need to stabilize these in the process of rehabilitation.”
Thomas Truelsen MD PhD, of the World Health Organization in Geneva, said different types of treatments are available in Europe, depending on the country and whether it is a rural or urban area. Non-pharmacological intervention includes dietary advice and encouragement of physical activity.
“These interventions could lower blood pressure and decrease the risk of developing diabetes and other cardiovascular diseases,” said Truelsen. “It is also important to encourage patients not to smoke and support smokers who are trying to quit.”
Pharmacological intervention for the management of hypertension can also be a component of stroke treatment.
“The systolic blood pressure should not exceed 140 mm Hg,” said Truelsen. “Persons with several risk factors may need to have their blood pressure lowered even more.”
For patients with diabetes, it is imperative that blood sugar concentrations are well controlled through physical activity and diet and when necessary, through pharmacological intervention.
“Additionally, anti-coagulation therapy may be a choice in patients with atrial fibrillation,” said Truelsen.
For acute treatment, patients with ischemic stroke admitted shortly after the start of onset of symptoms may be candidates for thrombolysis (tissue plasminogen activator, tPA).
“This treatment, however, must be initiated within a maximum of three hours after symptoms’ onset,” Truelsen said.
Unfortunately, only few stroke patients are admitted to a hospital that soon and only a small percentage of those patients get treated.
“It is often only hospitals in the larger urban areas that have the capacity to do thrombolysis,” Truelsen said.
Studies have shown that stroke patients have a better outcome if they are admitted to specialized stroke units where the staff are specially trained to take care of them.
Besides nursing and medical treatment, said Truelsen, rehabilitation is central for this group of patients.
“The highest possible level of independence at discharge is the goal.”
Moira Keating MSc BSc (HONS) RGN a specialist nurse in stroke care, Colchester General Hospital, Colchester, England, said thrombolysis as a treatment for stroke is limited to major hospitals and has to be part of a clinical trial.
“Local district general hospitals of the type in which I work, aim to meet the Royal College of Physicians National Stroke Guidelines in all aspects of care of stroke patients,” said Keating. “We are also working toward government directed National Service Frameworks in terms of care provision and service standards.”
According to Dániel Bereczki MD PhD DHAS professor of neurology, Department of Neurology, University of Debrecen, Debrecen, Hungary, in some of the former Eastern Block countries, thrombolysis is available for those with ischemic stroke. But again, only a small number of patients can get this therapy due to delay from stroke onset to arrival to the hospital.
“Additionally, stroke units have been organized in Hungary and some other former Eastern Block countries,” said Bereczki. “Aspirin is also available and is used in most Central and Eastern European countries.”
For secondary prevention, depending on the cause of the stroke, antiplatelets, anticoagulants or carotid endarterectomy are in practice. Statins and hypertensive drugs are also available.
Bereczki added that in the acute setting, mechanic compression (compression stockings) are used to help prevent deep vein thrombosis. Physiotherapy is started early. In case of total plegia, passive movement is used.
“For those who cannot stand by themselves due to the severity of paresis of the lower extremity, we use a standing machine that supports the patient in a standing position,” said Bereczki. “This practice is started as soon as possible after stroke, initially for ten minutes, increasing to 30 minutes over time. It is repeated several times during the day.”
This treatment not only helps prevent some complications of stroke, like hypostatic pneumonia, said Bereczki, but also speeds up rehabilitation.
“For those with less severe paresis, there is a physiotherapist room available with parallel bars, a room-bicycle and other equipment. To practice hand movements, there are special building elements used to improve skills.”
Keating pointed out that services across England are developing at different rates.
“Nationally, there is an objective to provide the same standard of service and provision of care across England,” she said. “Stroke services in the National Health Service are currently being driven to meet this objective through our government’s National Service Framework in Stroke.”
Botox for treatment of spasticity
Botulinum toxin type A (Botox) has been used for more than a decade to treat spasticity or spastic paralysis following strokes and other conditions. With spasticity, mobility becomes difficult or impossible and voluntary muscles are often disabled. Upon injection around specific muscles, the chemical messages that cause the muscles to contract are temporarily blocked, allowing the muscles to relax. The effects last from three to five months.
As far as an adjunct to orthotic fitting, Lupinacci believes botulinum A can be extraordinarily effective in some patients.
“We can inject Botox into those muscles that are specifically affected by spasticity,” he said. “The damaged nerves are telling the muscles to constantly contract.”
Not only does the patient have weakness, but also stiff muscles that do not behave normally. To circumvent the stiffness, particularly in the calf muscles and upper extremity muscles (which are the most commonly dysfunctional muscles in the stroke patient), botulinum A is injected into those areas so that they become relaxed, allowing for a more appropriate fitting of a brace.
“I think the best time to use Botox is early in the course of recovery when the spasticity just begins to set in,” Lupinacci said. “During this period, spasticity gets in the way of recovery. It may not be going away fast enough so we push it out of the picture until natural recovery releases the spasticity so normal strength can return.”
Lupinacci noted that botulinum A can be repeated every three to four months in those patients with chronic spasticity. But, as with any medical treatment, if it ceases to be effective, it should be discontinued.
“Probably two to three courses of the Botox would be sufficient,” said Lupinacci.
Follow up care and prevention
Bereczki’s stroke unit offers patients follow up initially at one to three months after stroke, then every six months or more frequently if needed. Prescribing drugs for secondary prevention (ticlopidine and clopidogrel) requires follow up every one to two months due to local regulations, he said.
“In our unit, there is an outpatient service organized for the follow up of stroke patients three days per week, three hours a day,” said Bereczki.
Truelsen said the WHO is making strong efforts to reduce tobacco smoking. Guidelines for management of risk factors for stroke have been published, and in the future, the beneficial impact of a healthy diet and physical activity will be a priority.
“Access to, and costs of medical treatment are other important aspects that need to be considered,” said Truelsen.
Stroke treatments and diagnostic tests
The U.S. Food and Drug Administration has approved tissue plasminogen activator (tPA) for the treatment of stroke and heart attack. According to the American Heart Association, if tPA is administered within the first three hours of a stroke, it can reduce permanent disability. It is a thrombolytic agent (clot-busting drug) used in ischemic stroke.
Carotid endarterectomy is a surgical procedure used to prevent strokes. Basically, the procedure involves exposing the artery in the neck via an incision and removing the atherosclerotic plague that is causing the narrowing of the artery, thereby improving blood flow to the brain.
|Percutaneous Cerebral Angioplasty|
A balloon is placed in the area of the carotid artery that has narrowed as a result of athersclerotic plaque that has built up on the walls of the blood vessel. Narrowing (stenosis) of the vessel can cause a thrombus, impeding blood flow to the brain. The balloon is inflated, dilating the vessel, thereby increasing blood flow to the brain.
Advances in technology allow physicians to determine which part of the brain is affected by a stroke and determine more specifically what problems may occur. The tests are generally painless and can be done on an outpatient basis. A physician will determine which tests to use on a case-by-case basis:
- Carotid phonoangiography
- Computerized axial tomography
- Digital subtraction angiography
- Doppler ultrasound test
- Evoked response test
- Magnetic resonance imaging
- Radionuclide angiography
Source Healio O&P News
Use of ankle-foot orthoses following stroke, August 2009 NHS Healthcare Improvement Scotland
Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015, Hebert D, Lindsay MP, McIntyre A, Kirton A, Rumney PG, Bagg S, Bayley M, Dowlatshahi D, Dukelow S, Garnhum M, Glasser E, Halabi ML, Kang E, MacKay-Lyons M, Martino R, Rochette A, Rowe S, Salbach N, Semenko B, Stack B, Swinton L, Weber V, Mayer M, Verrilli S, DeVeber G, Andersen J, Barlow K, Cassidy C, Dilenge ME, Fehlings D, Hung R, Iruthayarajah J, Lenz L, Majnemer A, Purtzki J, Rafay M, Sonnenberg LK, Townley A, Janzen S, Foley N, Teasell R. Int J Stroke. 2016 Jun;11(4):459-84. doi: 10.1177/1747493016643553. Epub 2016 Apr 14.Also see
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