Download L4-Stroke-the-longer-term_Nov11

EXERCISE AFTER STROKE
Specialist Instructor Training Course
L4
Stroke: the longer term
Dr. Gillian Mead
Reader and Consultant
The University of Edinburgh
Overview of talk
• Stroke prevention (lifestyle and drugs)
• Longer term post-stroke problems
• Co-morbidities (and drugs for
comorbidities)
• Services for people after stroke
Learning Outcomes
At the end of this session, you should be able to:
• Describe the measures for stroke prevention
• Describe the impact of stroke in the longer term
• Demonstrate knowledge and understanding of the most
common co-morbidities of stroke, their medications, and
how these may impact on a person’s capacity to exercise.
• Explain the role of exercise in the context of stroke
prevention
• Outline the various services for people with stroke
• Identify relevant government policy and published national
guidelines on stroke
The University of Edinburgh
Secondary prevention (general)
•
•
•
•
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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)
Secondary prevention: general
Secondary prevention
• Ischaemic
– Antiplatelets (aspirin and dipyridamole, or sometimes
clopidogrel)
– Blood pressure lowering medication
– Cholesterol reduction
– Warfarin for atrial fibrillation
– Carotid endarterectomy for severe carotid stenosis
• Haemorrhagic
– Treat underlying cause (e.g. arteriovenous
malformation)
– Blood pressure lowering medication
Drugs for secondary stroke prevention (STARTER n=66)
80
%
70
60
50
40
30
20
10
0
antiplatelets
anticoagulants
ACE-
thiazide
beta-blockers
calcium antag
alph blockers
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
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
Shoulder pain
• Affects 25% of
patients
• More common in
severe strokes
• Causes are
multifactorial
• Optimum treatment
uncertain
• Advice from
physiotherapist
Central post-stroke pain
• Burning, icy, lancinating, lacerating,
shooting, stabbing, clawing
• May respond to antidepressants
(amitryptiline), anticonvulsants
(gabepentin)
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
va
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Study
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02
02
20
07
20
06
20
05
20
20
01
20
20
01
19
99
19
83
Prevalence (%)
Prevalence of fatigue after stroke
80
70
60
50
40
30
20
10
0
Potential mechanisms of poststroke fatigue
Stroke
Pain
Depression
Direct physical mechanisms
Sleep disturbance
Treatment
Reduced mobility
FATIGUE
Behavioural avoidance and de-conditioning
Adapted from Wessely, Hotopf and Sharpe 1998
therapy
Mood disorders
• Depression in around 25%
• Anxiety in around 20%
• Emotionalism (20%) sudden outbursts of
laughing or crying
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
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
Co-morbidities in STARTER
%
50
45
40
35
30
25
20
15
10
5
0
hypertension
IHD
Cancer
Diabetes
LVF
arthritis
other
Drugs for co-morbidities in
STARTER n=66
25
%
20
15
10
5
0
analgesics
ulcer drugs
inhalers
steroids
thyroxine
diuretics
digoxin
antidepress
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’
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)
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
Department of Health: National
Stroke Strategy
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•
•
•
•
•
•
•
•
•
•
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
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
Essential Reading
Further detail about the topics discussed in this
session can be found in section L3 and L4 of
the course syllabus.
The University of Edinburgh