EXERCISE AFTER STROKE Specialist Instructor Training Course L4 Stroke: the longer term Dr. Gillian Mead Reader and Consultant INTRODUCTION Thanking organisers Remit: title potentially holds a LOT -> continuous decision-making as to what to exclude; hoping I have made the right decisions! Selection criteria: Focus on relearning (not compensation) -> Strategies used or useable by therapists -> Focus on stroke: largest population of people with a neurodisability, most research done with this group-> Focus on UL: poor recovery compared to LL in stroke, important for many people in their ADL and participation. 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) 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 Haemorrhagic 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)

Drugs for secondary stroke prevention (STARTER n=66)

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 Non-stroke related 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

Prevalence of fatigue after stroke The prevalence of fatigue depends on how fatigue is defined, Tools for measuring fatigue Methods of applying tools e.g. postal questionnaires, telephone questionnaires, face-to-face interviews Inclusion or exclusion of depression Patient groups Time after stroke,

Potential mechanisms of post-stroke fatigue Pain Depression Direct physical mechanisms Treatment Sleep disturbance Reduced mobility FATIGUE Behavioural avoidance and de-conditioning therapy Adapted from Wessely, Hotopf and Sharpe 1998 Several mechanisms may underlie fatigue, including depression, treatment, behavioural avoidance of exercise and deconditioning. What is the evidence for these mechanisms?

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

Drugs for co-morbidities in STARTER n=66

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 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