EXERCISE AFTER STROKE Specialist Instructor Training Course L4 Stroke: the longer term Prof. Gillian Mead Consultant

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EXERCISE AFTER STROKESpecialist Instructor
Training CourseL4Stroke the longer
termProf. Gillian Mead Consultant
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Secondary prevention (general)

• Healthy diet
• Exercise
• Alcohol
• Weight reduction
• Stop smoking
• Advice given at time of stroke, advice reinforced
  after hospital discharge by GP, practice nurse
• (see CHSS, SA, Different Strokes information
  leaflets)

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Secondary prevention

• Ischaemic
• Antiplatelets (e.g. aspirin, clopidogrel or
  occassionally dual antiplatelets)
• Blood pressure lowering medication
• Cholesterol reduction
• Warfarin or one of the newer oral anticoagulants
  e.g. apixaban, dabigatran, Rivaroxaban e.g.
  atrial fibrillation or if blood clot demonstrated
  in the heart
• Carotid endarterectomy for severe carotid
  stenosis (if on the side of the stroke lesion)
• Haemorrhagic
• Consider treatment of underlying cause (e.g.
  arteriovenous malformation)
• Blood pressure lowering medication

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Drugs for secondary stroke prevention (STARTER
n66)
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Longer term problems after stroke (relevant to
exercise delivery)

• Pain
• Fatigue
• Mood disorders (anxiety, depression,
  emotionalism)
• Falls and fractures
• Cognitive impairment
• Seizures
• Infections (urine, chest most common)
• Bladder and bowel problems
• Contractures

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Pain is common

• Stroke related pain
• Complications e.g. DVT
• Central post stroke pain (typically burning,
  shooting)
• Shoulder pain (hemiparetic side) in 25
• Pressure sores
• Limb spasticity
• Non-stroke related
• e.g. arthritis

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Shoulder pain

• Affects 25 of patients
• More common in severe strokes
• Causes are multifactorial
• Optimum treatment uncertain
• Advice from physiotherapist

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Central post-stroke pain

• Burning, icy, lancinating, lacerating, shooting,
  stabbing, clawing
• May respond to antidepressants (amitryptiline),
  anticonvulsants (gabepentin)

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Falls

• In the first six months after discharge, half to
  three-quarters of patients fall
• Causes
• Patient related factors e.g. muscle weakness and
  wasting, incoordination, loss of awareness of
  midline
• Environment e.g. uneven floors, footwear
• Drugs e.g. sedatives, antihypertensives

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Prevalence of fatigue after stroke
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Potential mechanisms of post-stroke fatigue

• Stroke
• Pain Depression Direct physical
  mechanisms Treatment
• Sleep disturbance
  Reduced mobility
• FATIGUE
• Behavioural avoidance and de-conditioning
  therapy
• Adapted from Wessely, Hotopf and Sharpe 1998

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Mood disorders

• Depression in around 25
• Anxiety in around 20
• Emotionalism (20) sudden outbursts of laughing
  or crying

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Cognitive impairment

• Memory and thinking problems
• May precede stroke or occur as a result of stroke
• Affects around 20 of patients at 6 months (MMSE
  of 23 or less)
• Can get worsening of cognitive impairment as a
  result of other medical problems e.g. infection

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Co-morbidities

• Diagnosable condition which exist in addition to
  main condition
• May have caused stroke (e.g. atrial fibrillation)
  
• Co-morbidity e.g. angina may be caused by a
  common risk factor (e.g. high blood pressure)
• May be unrelated to stroke e.g. gout

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Co-morbidities in STARTER
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Drugs for co-morbidities in STARTER n66
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Relevance of co-morbidities to exercise delivery

• Hypertension drugs may cause postural
  hypotention and dizziness, beta-blockers
  measurement of pulse rate to measure intensity of
  exercise
• Ischaemic heart disease exercise can carry
  risks.
• Avoid if unstable angina
• Exercise within limitations of stable angina.
• Congestive cardiac failure tailor to
  breathlessness and fatigue
• Diabetes mellitus exercise may precipitate
  hypoglycaemia. Seek medical advice prior to
  taking up classes. Strategies may include
• Reduction of insulin dose prior to exercise
• Take additional carbohydrate prior to exercise.
• Avoid injecting insulin into exercising muscle as
  absorption increases and so risk of hypos

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Services for people after a stroke

• In-patient care (rehabilitation, terminal care,
  long-term NHS care)
• Out-patient care (e.g. neurovascular clinics)
• Early supported discharge services
• Primary care team
• GP (quality outcomes framework)
• District nurse
• Practice nurse
• Respite care, day hospital
• Domiciliary physiotherapy
• Long-term nursing home care
• Charities (e.g. advice lines, CHSS stroke nurses)

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Younger stroke patients

• 25 of patients are under 65
• Similar neurological effects as older patients
• Need to consider impact on employment, finances
  and relationships
• All age stroke units, young stroke units
• In Lanarkshire young stroke worker
• Different Strokes charity set up by younger
  stroke patients for younger patients

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Department of Health National Stroke Strategy

• 10 point action plan
• Awareness (recognition of symptoms)
• Preventing stroke
• Involvement
• Acting on warnings
• Stroke as a medical emergency
• Stroke unit quality
• Rehabilitation and community support
• Participation (planning housing, transport)
• Workforce (skill mix)
• Service improvement

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Summary

• Early management of stroke
• Acute treatment (aspirin and clot busting drugs
  for ischaemic stroke)
• Secondary prevention (aspirin, antihpertensive
  drugs, statin, warfarin, carotid endarterectomy)
• Rehabilitation (on a stroke unit by a
  multidisciplinary team)
• Long-term problems (pain, fatigue, cognitive
  impairment, mood disorders, falls, infections)
• Co-morbidities (ischaemic heart disease, diabetes
  have important implications for exercise
  delivery)
• Stroke in a national context stroke strategies
  exist for UK

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Essential Reading

• Further detail about the topics discussed in this
  session can be found in section L3 and L4 of the
  course syllabus.